Client Intake & Health History

By signing below, I acknowledge and agree to the following terms:

I confirm that I have completed this client intake form truthfully, accurately, and to the best of my knowledge. I agree to promptly inform my esthetician of any changes to the information provided on any page of this form.

I acknowledge that I have been informed of, understand, and accept all contraindications associated with the requested treatments. I affirm that I do not have any medical conditions or circumstances that would make these treatments unsafe or unsuitable for me.

I agree to immediately notify my esthetician if I experience any discomfort during treatment so that appropriate adjustments may be made.

I hereby release and hold harmless my esthetician and/or Ditzy Chic Esthetics from any liability, claims, or damages arising from inaccurate or incomplete disclosure of my health history.

in light of the Coronavirus (COVID-19) outbreak,Ditzy Chic Esthetics is implementing additional precautions to mitigate the spread of this contagious disease. Kindly read this form thoroughly. We request our clients to provide truthful and accurate information regarding their health history. Please check below if you are currently experiencing any of the following symptoms.

1. By signing below, I affirm the following:

    

2. I, along with members of my household, have not experienced any symptoms listed above in the last 14 days.

3. I, along with members of my household, have not received a diagnosis of Coronavirus (COVID-19) in the last 14 days.
   my esthetician and Ditzy Chic Esthetics cannot be held liable for Coronavirus (COVID-19) exposure due to misinformation on this form or provided health history.

4. If I pursue legal action against "my esthetician and Ditzy Chic Esthetics," I am responsible for all associated attorney's fees and costs.

5. I, along with members of my household, have not traveled internationally in the last 15 days.

6. I, along with members of my household, do not believe we have been exposed to COVID-19.

7. By signing below, I release and hold "Ditzy Chic Esthetics" harmless, waiving any causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or property. I release "Honey Bee Skin" from liability for unintentional exposure or harm due to COVID-19.

I hereby grant permission to Ditzy Chic Esthetics to capture photographs, videos, or other media for use in marketing, advertising, social media, website, newsletters, magazines, recruiting brochures, emails, books, and general publications.

I waive any right to inspect or approve the finished photographs or electronic matter that may be used now or in the future, whether known or unknown to me. Additionally, I waive any right to royalties or other compensation related to the use of the image.

I confirm that I am at least 18 years old and competent to contract in my own name. Having read this release, I fully understand its contents, meaning, and impact. I acknowledge that I can address any questions about this release in writing before signing. I agree that my failure to do so will be considered a free and knowledgeable acceptance of the terms of this release.

By signing below, I willingly consent to and authorize Brakamy De La Cruz,My Esthetican or Ditzy Chic Esthetics to perform services within the scope of cosmetology aesthetics and I have chosen to undergo this treatment after receiving a comprehensive explanation of its nature, purpose, and associated risks and hazards from Brakamy De La Cruz/or Ditzy Chic Esthetics esthetician. While it is impossible to enumerate every potential risk and complication, I have been briefed on the possible benefits, risks, and complications of today's procedure.

I acknowledge that there are no guaranteed results, and individual outcomes depend on factors such as age, skin condition, lifestyle, and others. To achieve optimal results, I understand that additional treatments may be necessary, incurring additional costs. I have thoroughly read and comprehend the post-treatment home care instructions, recognizing the importance of following them diligently.

In the event of questions or concerns about my treatment or post-treatment care, I commit to promptly contacting my esthetician at (254-349-9201). I affirm the accuracy and truthfulness of my medical history, including all known allergies and current usage of both ingested and topical prescription drug products.

I have read and fully understand this agreement, and all my inquiries have been addressed to my satisfaction. I consent to the terms outlined in this agreement and agree not to hold Brakamy De La Cruz/Ditzy Chic Esthetics esthetican responsible or liable for any undisclosed medical conditions that may be affected by today's procedure.

Galvanic & High-Frequency Treatment Information
Galvanic and high-frequency treatments use low-level electrical currents to enhance skin health and improve treatment results.

Galvanic treatment helps professional products penetrate deeper into the skin and softens oil, debris, and keratin within the follicles, making extractions easier—especially for oily or acne-prone skin.

High-frequency treatment uses a gentle electrical current passed through a glass electrode to generate oxygen-enriched molecules. This process helps kill acne-causing bacteria, increase circulation, stimulate collagen and elastin production, and improve the appearance of fine lines and wrinkles.

Contraindications & Safety Information
These treatments are not recommended for clients with any of the following conditions:

Pacemakers, metal implants, braces, or excessive dental fillings
Heart conditions or high blood pressure
Epilepsy or seizures
Pregnancy
Chronic headaches or migraines
Reduced nerve sensitivity (such as diabetes)
Fever, active infection, or open/broken skin (including wounds or recent scars)
Clients may experience mild warmth, tingling, or a metallic taste during treatment. All jewelry must be removed prior to treatment. Clients are required to inform their esthetician immediately if any discomfort occurs.

 

Light-Emitting Diode (LED) therapy, inspired by NASA research, uses specific wavelengths of light to stimulate cellular activity, promote tissue repair, and enhance collagen production. This non-invasive treatment helps reduce the appearance of fine lines and wrinkles, calm inflammation, and improve overall skin health. LED therapy is painless, requires no downtime, and has been shown to be effective for aging skin, acne, rosacea, and hyperpigmentation.

Contraindications:
LED therapy is not recommended for clients who are pregnant or breastfeeding, have epilepsy or a history of seizures, have recently received cortisone or steroid injections, or are taking photosensitizing medications. Clients should consult their physician prior to treatment if they have any medical concerns.

LED Light Colors & Benefits
Red Light: Stimulates collagen production, reduces fine lines and wrinkles, and helps improve hyperpigmentation.
Blue Light: Targets and reduces acne-causing bacteria to help prevent breakouts.
Violet Light: Promotes cell renewal, supports skin cleansing, and reduces inflammation.
Yellow Light: Calms redness, reduces inflammation, and helps improve sun damage, rosacea, and other sensitive skin conditions.

 

Please ensure you are aware of the location where you will be seen, as providers practice at different addresses: Please Reach out to Ditzy Chic Esthetics 254-349-9201 or email Ditzychicesthetics@gmail.com

• Bee De La Cruz
  4604 Memorial Drive E
  Waco, TX 76711 
• 
  Christel Flores
  4604 Memorial Drive E
  Waco, TX 76711
• 
  Baybay Hutchens
  2508 Washington Ave, Suite 3
  Waco, TX 76710