Facial Intake/Consent Form

Client Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please take a moment to answer the following questions

Do you consent to photos or videos being taken during the service that may be posted on social media?

Are you pregnant?

Do you have any allergies to cosmetics, food or drug?

Please specify

Are you using a retinol?

Have you had skin cancer?

Are you currently on Accutane/have been in the last 6 months?

Skin Type:

Acne?

Please check if you are affected by or have any of the following

Main skincare concern + goal

I agree with If I experience any pain or discomfort during the session, I will immediately inform Kaili so that the products and/or technique may be adjusted to my level of comfort. I further understand that a facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I agree to keep Kaili updated as to any changes in my medical profile during the session and understand that there shall be no liability on Kaili Piluso Esthetics part should I fail to do so. Also I understand, acknowledge and agree that the esthetician is not responsible for any doctor co-pays or bills that may occur after the procedure. I understand this concent agreement is legal and binding and I will not hold Kaili Piluso and Kaili Piluso Esthetics at fault for any liability that may result from this treatment. By signing below I agree to the terms listed above.

Client Signature

Date