Serene Skin OC Client Intake Form

  • Serene Skin OC Facial Intake Form

    Please take a few moments to fill out this form. This is to ensure your understanding and safety during your service. **Please note: This form will only need to be filled out once per year. If there are any updates or changes it is your responsibility to inform me. For any questions/concerns, feel free to contact me at (714)393-5042.
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  • Date of Birth*
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  • Have you ever recieved a facial before?*
  • What do you hope to achieve from this treatment?*

  • Do you wear any contact lenses? IF YES, please remove during service.*
  • Do you have any allergies?*
  • If yes, please chose any that apply.

  • Have you taken Accutane in the past 12 months?*
  • Do you have any metal implants, metal dental work, piercings, or wear a pacemaker?*
  • Do you have any of the following conditions?*

  • Do any of these apply to you?*

  • **WARNING** If you selected any of the following above, please note that you may be contraindicated to receiving a specific serive. If you are using any of the products and/or medications above, discontinue use for a MINIMUM of 7 days before service to reduce risk of negative reactions. Please contact me, Kayla, at (714)393-5042 with any concerns or to reschedule appointment.

  • Are you pregnant, trying to become pregnant, and/or breastfeeding?*
  • Are you taking any hormonal cotraceptives?*
  • Do you consent to pictures and/or videos to be taken for progress and/or social media content?*

  • I hereby agree that I have cited all conditions and circumstances regarding my health history including medications being taken and any past reactions to products or medications that could prohibit or compromise this service. I understand that additional conditions could occur which could affect my ability to tolerate the treatment. I further understand there are risks associated. I acknowledge that my skin may experience temporary irritation, tightness, redness, purging breakouts, or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

  • I will not hold Serene Skin OC responsible in any way for any issues that may arise as a result of having this facial treatment. I understand that even though Serene Skin OC uses the proper technique with the utmost attention to safety and proper procedure protocols, the instruments and products used may cause irritation, breakouts, itching, or discomfort and may require a medical professionals follow up care.

  • I understand that aftercare needs to be followed. As as part of my aftercare, I should minimize prolonged sun exposure, avoid aggressive exfoliants, waxing and products containing acids that are not part of the recommended take home and aftercare regimen for 3-4 days following treatment. I acknowledge that if I fail to use min SPF 30, I am more susceptible to sunburn, skin damage, and hyperpigmentation.

  • You hereby acknowledge and confirm that you are or have been fully informed as to the nature of the service you have requested and are aware with all the risks associated. You have informed you technician of any pre-existing conditions, allergies, or product sensitivities that may impact your treatment. We are not liable for any dissatisfaction, discomfort, damage, loss or injury you may incur arising directly or indirectly out of any services provided or any product used. Complimentary services or treatments are only offered on the express understanding that the service offered is not and may not be deemed as an admission of liability or fault and are also subjected to the conditions of this agreement.

  • Date Signed
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