Skin Moment Esthetics Confidential Client Intake Form & Liability Waiver

General Information
Date*

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Name*

First NameLast Name
Date of Birth*

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Email*
example@example.com
Address

Street Address

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Phone Number*
Your Medical History
Check all that apply:

Currently PregnantDiabetesCancer/ Systemic diseaseEczemaFever BlistersHeart DiseaseHigh Blood PressureLow Blood PressureRashesSkin CancerHIV/AIDSLupusDepression/AnxietySeborrheaArthritisHype/Hypo ThyroidInsomniaWartsShinglesPsoriasisSinus InfectionEpilepsyHepatitisHyper PigmentationOther
Any known allergies?*
List medications/supplements you are currently taking.
Are you presently under a physician's care for any current skin condition?

YesNo
Skin Care History
What would you say your skin type / skin condition is?

NormalSensitiveCombinationOilyDryUnsure
Are you currently using any of the following ?

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A (retinol/retinoids)Exfoliating scrubsTopical Vitamin CHormone Replacement TherapyHydroquinoneSunscreen/Sun blockAccutanePrescribed Topical CreamOther
Have you ever used Accutane? If YES, when and for how long?
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Have you ever received chemical peels, laser services, or microdermabrasion treatments? If YES, when?
Please select all that apply :

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
I consent to having Before & After pictures taken of my face for documentation and treatment tracking.
Your Before & After pictures help support my business growth. Please indicate your level of comfort with sharing these images:

Okay to sharePlease don'tOkay to share but please make me unrecognizable

Facials and Back Treatments (click arrow to expand)
I understand my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible, however, I understand that any time I receive a facial or skin treatment there is always a small chance that reactions could occur, including but not limited to redness, rash, swelling, tenderness, etc. due to unknown allergies or sensitivities.

I am willing to follow recommendations made by my Esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home products/ post-treatment care, I will consult the Esthetician immediately.

I understand that my esthetician will perform a thorough skin analysis prior to my facial. If the treatment I have booked is not appropriate for my skin, I understand I will be informed during this session and an alternative treatment may be recommended instead.

MICRODEMRABRASION

I understand that microdermabrasion is a skin resurfacing procedure designed to exfoliate the outer layer of the skin, promoting skin rejuvenation and a smoother appearance.

I understand that this treatment may cause temporary redness, sensitivity, or mild discomfort during and after the session, which typically subsides within a few hours to a day.

I understand that microdermabrasion may not be suitable for certain skin conditions (such as active acne, rosacea, or broken capillaries) and that it's important to disclose any skin conditions or medical history to my provider before treatment.

I understand that it is essential to follow post-treatment care instructions, including using sunscreen, moisturizing, and avoiding harsh products or excessive sun exposure, to protect my skin and achieve the best results.

I understand that this treatment may sometimes leave stripes or red lines that resemble fine scratches. This is temporary and is related to skin sensitivity.

I agree to protect my skin with sunscreen due to increased photosensitivity from exfoliation.

LED LIGHT THERAPY

I understand there are certain contraindications that would preclude me from receiving LED treatments, including epilepsy, medications causing light sensitivity, open wounds, pregnancy, and thyroid conditions.

I understand there are other precautions that should be considered before receiving LED therapy treatments and may require a doctor’s release and/or I assume any risk involved.

I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.

I understand that some clients report slight tingling sensations and flashing of the optic nerve during the procedure.

I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

CHEMICAL PEELS

I understand that there are risks and complications associated with having a chemical or enzyme peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).

I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.

I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.

I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.

I understand that results are not guaranteed and for maximum results, more than one application 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 understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.

MICROCURRENT

I understand there are certain contraindications that would preclude me from receiving microcurrent treatments, including autoimmune disorders, diabetes, embolism, epilepsy, melanoma, metal implants including plates/pins/screws, open wounds, pacemaker use, phlebitis, pregnancy, thrombosis, and varicose veins.

I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment.

I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk.

I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.

I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure.

I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

I understand that it is imperative to my health that I disclose all of the information requested in the Client Intake Form.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

DERMAPLANING

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for dermaplaning treatment and must be disclosed prior to treatment:

Active acne, Active infection of any type, such as herpes simplex or flat warts, Any raised lesions, Any recent chemical peel procedure, Chemotherapy or radiation, Eczema or dermatitis, Family history of hypertrophic scarring or keloid formation, Hemophilia, Hormonal therapy that produces thick pigmentation, Moles, Oral blood thinner medications, Recent use of topical agents such as glycolic acids, alpha-hydroxy acids and Retin-A, Rosacea, Scleroderma, Skin Cancer, Sunburn, Tattoos, Telangiectasia/erythema may be worsened or brought out by exfoliation, Uncontrolled diabetes, Use of Accutane within the last year, Vascular lesions.

My esthetician will take every precaution to ensure that my skin is well hydrated and calm following each session. However, I understand that I may experience excessive dryness or even some peeling between sessions, which may or may not be normal. I will contact my esthetician if I have any concerns.

More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.

I understand that Dermaplaning may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this should occur, I will contact my esthetician so that she can do a post-treatment follow-up with me.

I understand that after my treatment, SPF 30+ MUST be worn at all times. Tanning beds should never be used.

Full Disclosure
I have completed this form to the best of my ability and knowledge. I agree to inform the Esthetician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the Esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward Skin Moment Esthetics LLC and Esthetician for any injury or damages incurred due to any misrepresentation of my health as a result of the treatment I will receive at Skin Moment Esthetics today and at all future appointments. Skin Moment Esthetics cannot and does not claim to diagnose or give advice on any medical conditions of the skin and/or otherwise. I agree to seek immediate medical attention and advice from a qualified physician or medical facility should any irritation or adverse reaction occur.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. 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 a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly 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 no part of the recommended take-home regimen for 2-4 weeks following treatment. 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 give consent for all future treatments I release Skin Moment Esthetics LLC and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

I understand that Skin Moment Esthetics reserve the right to refuse or discontinue service to anyone demonstrating behavior that is perceived to be inappropriate or disruptive to our atmosphere. I understand that if during my treatment my esthetician identifies a contagious or potentially-contagious skin condition (such as an active cold sore), she may ask me to reschedule my appointment for another time.

Cancellation Policy: We require at least 24 hours notice to cancel any appointment, and a credit card number is required to hold your reservation. Once an appointment is booked - unless we hear otherwise, we'll expect and are excited for you to be there. No show and same day cancellations will be charged 50% of the service(s) booked. By signing below, you acknowdledge and agree to this policy.
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General Information

Your Medical History

Skin Care History