• Client Intake and Consent Form

    Client Intake and Consent Form

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • How did you hear about Ana Csere Skin Care?*
  • Format: (000) 000-0000.

  • Medical History

  • Have you seen a Dermatologist in the past year?*
  • are you currently on or have you ever taken accutane?
  • Are you currently under the care of a physician or skin care therapist?*
  • Any recent surgery, including plastic surgery?*
  • Do you have or have ever had any of the following?*
  • Any known allergies (check all that apply)?*
  • Do you (check all that apply)?*
  • Do you suffer from sinus problems?*
  • Have you ever experienced claustrophobia?*
  • What is your current stress level?*
  • Regular exercise?

  • Female Clients Only:

  • Are you pregnant or breastfeeding?
  • Are you taking birth control or hormone replacement?
  • Any menopause issues?

  • Your Skin

  • Have you had a facial treatment before?*
  • If yes, when was your last facial or skin treatment?
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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 had an adverse reaction after using any skin care product?*
  • If yes, please check all that apply:
  • Have you had Botox or other injectables?*
  • If yes, date of last treatment?
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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?*
  • Sun Exposure
  • Do you use sunscreen?*
  • Indicate what services or areas for which you are interested in (check all that apply):

  • Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists' day that could have been filled by another patient. As such, we require 48 hours notice for any cancellations or changes to your appointment. Patients who provide less than 48 hours notice, or miss their appointment, will be charged a 50% of service cancellation fee to the card on file. No show appointments will be charged a cancellation fee and will forfeit rebooking with the provider.

  • I consent to photographs being used for medical education or publication with applied discretion and not revealing my identity

  • By signing this form, I consent to receive facials, skincare treatments, and eyelash/eyebrow services. I understand that these are cosmetic procedures only and that the esthetician does not diagnose conditions or prescribe medications. I confirm I have medical clearance if needed.

    I acknowledge potential risks, including but not limited to redness, irritation, swelling, bruising, soreness, or allergic reactions. I understand results and reactions vary, and temporary skin sensitivity may occur for up to 72 hours.

    I agree to disclose all medical conditions, medications, and changes to my health. I understand that failure to follow aftercare instructions, including daily SPF 30 use and limiting sun exposure, may increase risks such as sun damage or hyperpigmentation.

    I understand I may stop the treatment at any time and will communicate any discomfort. I confirm all information provided is accurate and complete.

    I consent to current and future treatments and release Ana Csere Skin Care LLC and its staff from any liability related to treatments or products.

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