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Client Intake and Consent Form
This intake and consent form covers ALL services, including but not limited to: Facials, Advanced Treatments, Waxing, and Lash/Brow Services. Any medical and personal information provided will be protected though strict legal client protection rights. By signing this form, Skin Society Hawaii LLC and it's employees are protected from any liability. You have acknowledged the risks associated with your service. 
26Questions
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    NAME AND PHONE #
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    Click next is N/A
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    Please select all that apply
    • Social Media (Instagram, Facebook)
    • Google
    • Yelp
    • Advertising (Ad/Flyer)
    • Marketing (Email, Text)
    • Friend/Referral
    • Classpass
    • Other
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    Click next if N/A
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    Click next if N/A
    • Normal
    • Combination
    • Oily
    • Dry
    • Unsure
    • Not Applicable
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    Click next if N/A
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  • 10
    Select all that apply
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    Click next is N/A
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    Click next if N/A
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    Click next is N/A
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  • 14
    If yes please explain >>>
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    Click next is N/A
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  • 16
    If yes, please explain >>>
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    Click next is N/A
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    If yes, please explain >>>
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    Click next is N/A
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    Select all that apply, or click next if N/A
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    Click next is N/A
    • Yes
    • No
    • Does not apply
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  • 22
    Click next if N/A
    • Yes
    • No
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    *Please note, if you are receiving an advanced treatment today (like microdermabrasion, dermaplaning, waxing, etc.) you need to stop using these ingredients at least 72 hours prior to your appointment. Click next if N/A.
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    Also known as Isotretinoin, Zenatane, Absorica, Myorisan, Claravis, and Amnesteem. Click next is N/A
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    I have voluntarily elected to undergo this service.

    Although it is impossible to list every potential risk and complication, I have been informed of the most commonly associated risks and contraindications with this service. I have had the opportunity to ask any questions I may have prior to my service. I, therefore, consent to not hold my esthetician or company liable for any issues, damages, or side effects that may occur.

    I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle, and that there is a possibility I may require further services in the treated areas to obtain the expected results, at an additional cost.

    I have read and understood all available pre and post-treatment care instructions, and acknowledge how medically important it is to follow these instructions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

    To the best of my knowledge, I have also given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I assume responsibility, and if I’ve failed to mention anything to my esthetician regarding my medical condition/history - they will not be held liable if any issues, complications, or damages arise. If my medical status changes, I will notify the company prior to my service. 

    I give consent to take photos of me for the purpose of client records, company education, marketing, and advertising. I also understand my personal information (such as name, email, phone number, etc.) will be held on file by the company. I understand the company may contact me through text, email, and social media for the purpose of business, marketing, and advertising. I understand I have the option to opt-out of any advertising and marketing at any time by doing so electively on those channels. 

    If I have any questions, I will reach out to the company as soon as possible. 

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    I have read and fully understand this agreement and all information detailed above.
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