• Client Intake & Consent Form

    (Confidential)
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • How did you hear about The Wildflower Esthetics?*
  • What service are you doing? :*

  • Medical History

    For Facials
  • Have you been sick, experienced any symptoms, or have come into contact with someone who has been sick/had symptoms in the past 2 weeks?*
  • Have you seen a Dermatologist in the past year?*
  • Any recent surgery, including plastic surgery?*
  • Do you have or have ever had any of the following? (check all that apply)*
  • Any known allergies/sensitivities (check all that apply)?:*
  • Do you (check all that apply)? :*
  • Do you suffer from sinus problems?*
  • What is your current stress level?*
  • Are you pregnant, trying or lactating?
  • Are you taking birth control or hormone replacement?

  • Your Skin

  • Have you had a facial treatment before?*
  • If yes, when was your last facial or skin treatment?
     - -
  • Are you currently using any products that contain or are you taking any of the following?*
  • Have you received any of these skin care treatments?*
  • If you checked any of the above, please select one:
  • Have you ever has an adverse reaction after using any skin care product?*
  • If yes, please check all that apply:
  • Have you had Botox/Dysport or other injectables?*
  • If yes, date of the last treatment?
     - -
  • What do you consider your skin type?*
  • Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*
  • Do you have frequent breakouts?*
  • What skin care products do you currently use?*
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  • Do you use sunscreen?*
  • Indicate what services or areas for which you are interested in (check all that apply):

  • Medical History

    For Lash Extensions/ Lash & Brow Lift
  • Have you been sick, experienced any symptoms, or have come into contact with someone who has been sick/had symptoms in the past 2 weeks?*
  • Are you currently taking any medication(s)?*
  • Any known allergies/sensitivities (check all that apply)?:*
  • Do you have, or are you being treated for any eye illness or injury?*
  • Are you pregnant, trying or lactating?*
  • Do you (check all that apply)? :*
  • Do you wear contact lenses or glasses?*
  • Do you have or have ever had any of the following? (check all that apply)*
  • What is your current stress level?*

  • Your Lashes & Brows

  • Did you do any of the following to your lashes?*
  • Is this the first time you have had lash extensions, lash lifting, etc. applied?*
  • What service(s) are you doing?*

  • Medical History

    For Spray Tans
  • Have you been sick, experienced any symptoms, or have come into contact with someone who has been sick/had symptoms in the past 2 weeks?*
  • Have you seen a Dermatologist in the past year?*
  • Are you currently taking any medication(s)?*
  • Any known allergies/sensitivities (check all that apply)?:*
  • Any recent surgery, including plastic surgery?*
  • Have you received any of these skin care treatments?*
  • If you checked any of the above, please select one:
  • Have you ever had an adverse reaction after using any skin/body care product?*
  • If yes, please check all that apply:
  • Do you have any allergies? (Acrylics, Latex, adhesives, synthetics, etc.)? :
  • Are you pregnant, trying or lactating?*
  • Do you have or have ever had any of the following? (check all that apply)*
  • Do you wear contact lenses?*

  • Your Skin

  • Do you (check all that apply)? :*
  • Have you ever applied self-tanner or been professional spray-tanned before?*
  • Have you shaved or waxed less than 24 hours ago?*
  • What skin/body care products do you currently use?*
  • How do you usually react to the sun?*
  • What is your skin condition?*
  • Is this spray tan for a special occasion?*
  • Did you moisturized your skin today?*
  • Have you removed all deodorant, perfume, and makeup?*

  • Medical History

    For Waxing
  • Have you been sick, experienced any symptoms, or have come into contact with someone who has been sick/had symptoms in the past 2 weeks?*
  • Are you currently taking any medication(s)?*
  • Any known allergies/sensitivities (check all that apply)?:*
  • Any recent surgery, including plastic surgery?*
  • Do you have or have ever had any of the following? (check all that apply)*
  • Are you pregnant, trying or lactating?*

  • Your Skin

  • Have you received any of these skin care treatments?*
  • If you checked any of the above, please select one:
  • What is your skin condition?*
  • Are you currently using any products that contain or are you taking any of the following?*
  • Have you shaved or waxed less than 24 hours ago?*
  • Have you exfoliated your skin/body less than 24 hours ago?*
  • Have you had Botox/Dysport or other injectables?*
  • Have you been waxed before?*
  • If yes, when was the last time you were waxed?
     - -

  • Liability Release Form

  • By SUBMITTING & SIGNING THIS FORM, I acknowledge, consent and agree to the following: I give my permission to receive facials, skin care treatments, lash and brow treatments, waxing and/or spray tans. I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my esthetician. I understand that results are not guaranteed and for maximum results, more than one service may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne conditions. I have been informed of the possible negative reactions and the expected sequence of the healing process. (Drying, irritation, redness, and peeling of the skin). I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications. I have clearance from my physician to recieve facials, skin treatments, lash and brow treatments, waxing and/or spray tans. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure. I acknowledge that these treatments are strictly an elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment. I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes of these. I understand that there may be additional risks based on my physical condition. I understand that it is my responsibilty to inform my esthetician of any discomfort I may feel during the session so he/she may adjust accordingly. I understand that I or the esthetician may terminate the session at any time. If I have questions or concerns, I will address these with my esthetician before seeking outside sources. I have been given a chance to ask questions about the session and my questions have been answered. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my esthetician. I, therefore, release, The Wildflower Esthetics, and its staff of from all and any liability associated with any injuries and/or current and future conditions resulting from the skincare, lash and brow treatments, waxing and spray tan procedures or products. I understand, have read and completed these questionnaires truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

  • Photo & Video Release Form

  • I, hereby, grant and authorize, The Wildflower Esthetics, and its staff, the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures and video and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites, and other print or digital communications without payment or any consideration. This authorization extends to all languages, media, formats, and markets now known and later discovered. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By signing this form, I acknowledged that I completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes, social media posts, promotional marketing and those previously listed in this agreement.

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