• Esthetician Client Intake Form

  • Gender
  • Date of Birth*
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  • Format: (000) 000-0000.
  • How did you hear about us?*

  • Your Health

  • Do you have any of the following conditions? If yes, please select them:*
  • Do you?*
  • Have you used or been prescribed any medications (topical or oral) for acne/acne control?*
  • Do you consume alcohol?*
  • Are you a smoker?*
  • Are you pregnant?*
  • Are you trying or planning to be pregnant?
  • Are you breastfeeding?
  • Do you consume caffeinated drinks?*
  • Have you undergo any surgeries?*

  • Your Skin

  • Skin condition
  • How does your skin heal?*
  • Have you ever had a facial or skin treatment before?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any of these hair removal services in the last 30 days?*
  • Have your ever received chemical peels, laser services, or microdermabrasion treatments?*
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*
  • Do you allow Heather's Beauty Galore to use your photos for the purpose of education through our Instagram / Facebook Page? (No personal information will be released.)*

  • Terms & Conditions

  • Post Facial Care / Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any string UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum of SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitized to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can results in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.

  • I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.  I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
  • Date Signed
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