Client Intake Form

Client Intake Form
Client's Name*

First NameLast Name
Preferred Name:*
Pronouns:*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Skin Revival Studio?*
If someone referred you to us, what is their name?
What are you seeking?*

Help with your home care regimenHelp addressing skin concernsRelaxation
Skin type*

NormalOilyDryComboReactive (also known as sensitive)Not sure
How does your skin heal?*

FastPigments (includes red/brown marks post-acne)Scars (indentations/divots in the skin)SlowOther
How does your skin respond to sun exposure?*

Always burns, never tansUsually burns, tans with difficultySometimes mildly burns, gradually tans to oliveRarely burns, tans easily to moderate brownVery rarely burns, tans very easilyNever burns, always tans
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringMelasmaSensitivityDryness
How are your stress levels currently?*

LowMediumHighVery high
How many hours of sleep are you getting on average daily?*

Less than 5 hours6-7 hours7-8 hours8+ hours
How much is your water intake on average daily?*

Less than 20 oz a day20-40 oz a day40-60 oz a day60+ oz a day
Have you had a facial or skin treatment before?*

YesNo
If yes, please explain what treatments you’ve had in the past:
What is your current skin care regimen?*

Face WashBar SoapFace Scrub / Chemical ExfoliantTonerSerumsMoisturizerSunscreenEye + Lip CareNone
What skincare and/or cosmetic products are you currently using?
Please make sure to include a photo of your AM/PM routines. Thank you!*

Cancelof
Do you or have you used Retin-A/tretinoin, adapalene, Accutane, Differin, or retinol?*

Yes, currently usingYes, but not within the last 14 daysYes, but not within the last 30 daysNo
If yes, please identify which one you're using (Retin-A/tretinoin, adapalene, Accutane, Differin, or retinol)
*PLEASE REFRAIN FROM USING RETINOL, DIFFERIN, AND RETIN-A 2 WEEKS PRIOR TO YOUR APPOINTMENT.

*PLEASE DO NOT USE ANY FACIAL SCRUBS / EXFOLIANTS 1 WEEK PRIOR TO YOUR APPOINTMENT.

*IF YOU ARE CURRENTLY ON ACCUTANE OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT YOUR DOCTOR BEFORE SCHEDULING YOUR APPOINTMENT.
Are you currently in a dermatologist’s care?*

YesNo
Are you taking any topical or oral prescribed medications related to cosmetic or skin improvement? If so, please list them below.
Are you taking any vitamins or supplements daily/weekly? If so, please list them below.
Are you currently under any special type of diet (i.e. gluten-free, vegan, vegetarian, keto, etc)?

YesNo
If yes, please explain:
Have you received any of these hair removal treatments on the face in the last 2 weeks?*

WaxingSugaringThreadingLaser Hair RemovalDepilatory CreamNone
Have you received a chemical peel, cosmetic laser, or microneedling recently?*

Yes, within the last monthYes, within the last 2-3+ monthsYes, within the last 6-12 monthsNo
If answered yes above, please identify which treatment(s) you've received recently (chemical peel, cosmetic laser, or microneedling)
Have you received any Botox or filler in the past 2 weeks?*

YesNo
Do you consume alcohol?*

YesNo
Do you smoke?*

YesNo
Are you using hormonal birth control?*

YesNoWill be using soonWill be stopping soon
If so, please list:
Are you undergoing any hormone replacement therapy?*

YesNo
Are you pregnant?*

YesNo
Are you trying or planning to be pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Do you have a history of any of the following conditions? If yes, please select them:*

CancerHypertensionHypotensionPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsHigh Blood PressureArthritisAuto Immune DiseaseAsthmaCold Sore / Fever Blister(s)LymphedemaStrokeOther
Have you undergone any surgeries within the last two years?*

YesNo
If yes, please explain:
Are you currently on any blood thinners?*

YesNo
Do you experience chronic pain? If so, where?*
Do you:*

Wear contact lensesHave a pace makerHave metal implantsHave facial piercingsNone
Any known allergies to:*

AspirinTree NutsLatexDairyIodineFragrance / Essential OilsOtherNone
Do you have any sensitivities to fragrances? If no, type N/A. If so, please explain:*
Do you have any allergies or sensitivities to anything orally/topically? Includes medications. If no, type N/A.*
Have you had any reactions to any skincare/makeup? If no, type N/A. If so, please explain:*
*SKIN REVIVAL STUDIO WILL NOT BE HELD RESPONSIBLE FOR ANY ALLERGIC REACTIONS DUE TO UNDISCLOSED ALLERGIES
What are your day + time preferences for scheduling? Latest PM appointment on M, W, TH is 3:30pm; on Fridays - 4:30pm // You can choose as many options!*

Monday AMMonday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PM
Do you release consent for your photos to be taken for client progress history? (It is*

YesYes, with eyes covered
Do you release consent for your photos to be used for social media/marketing purposes?*

YesYes, with eyes coveredNo
Treatment + Consent

Please read + sign acknowledging you understand and agree to each statement:
I understand that my facial treatment may include clincal-strength products, enzymes, acid peels, and other treatment modalities (i.e. Microdermabrasion, steam, extractions, nano infusion, LED light therapy, and high frequency) as necessary or requested.

I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment, and I need to follow the maintenance home protocol.

I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience actual "peeling" with peels as each case is individual.

I understand that there may be some degree of discomfort, i.e. stinging, prickling sensations, hotness, or tightness.

I understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for a medical treatment.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact my Service Provider.

I have voluntarily elected to undergo treatments at Skin Revival Studio after the natureu and purpose of this treatment has been expalined to me, along with the risks and hazards involved.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.

I acknowledge that this therapy and the treatments involved have no sexual intent and touching the therapist is strictly prohibited.

I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concernsn regarding my treatemtn or suggested home product/post-treatment care, I will consult the Service Provider immediately.

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection from a minimum SPF 30 is mandatory.

I will reveal any medical condition that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment, with the exception of Accutane, which must be discontinued for six months prior.

I have not had a peel treatment of any kind within 14 days of my treatment from my Service Provider or any other Service Providers. I understand I cannot have another treatment until recommended by my Service Provider. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by my Service Provider.

PHOTOGRAPHS: I give permission for photographs to be used by my Service Provider for monitoring my treatment progress.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform my Service Provider of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

I have read the contents of this consent form carefully, and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions been answered to my satisfaction. I hereby release Skin Revival Studio (Esther Oh and/or The Korean Esthetician) against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.

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.

With my signature below, I give consent to receive ALL treatments (includes: Bespoke Korean Treatments, Barrier Revival Treatemnt, Firming Peptide Treatment, Custom Corrective Peels, Light Chemical Peels, Sorella Signature Facial, etc) from Skin Revival Studio and have read and completed this questionnaire truthfully.

I understand I will be receiving professional services from a licensed Service Provider. I further understand that Skin Revival Studio or any Service Provider at Skin Revival studio neither diagnoses illness, disease, or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have.

Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations, and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.

If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider for any services rendered. I release Skin Revival Studio and its Service Providers of any responsibility in case of an accident, illness, or injury.
Client Signature

Clear
I understand and agree to comply with all of Skin Revival Studio's policies:

1. I will not treat clients with questionable medial conditions such as Herpes Simplex (active cold sores and fever blisters), open wounds or sores, healing incisions, infectious diseases, etc. I do not manage clients undergoing cancer, diabetes, or systemic treatments of any specific contraindications for the body.

2. I require a minimum of 48 hours advance cancellation notice. Any client giving less will be charged 50% of the service fee. Any clients who No Calls + No Shows their appointment will be charged 100% of the fee. Any clients who arrive 15 minutes after their appointment time will be charged 100% of the appointment fee.

3. If an appointment is rescheduled for the second time, a nontransferable, nonrefundable deposit of 50% of the service fee will be made via electronic invoice before the second rescheduled appointment request is accepted.

4. I understand that services received here are NOT a substitute for MEDICAL CARE and any information provided by the technician is for educational purposes only.

5. All information received by the client on this chart is completely private and confidential.

6. ALL SALES ARE FINAL.
Signature

Clear
PLEASE MAKE SURE TO BOOK A CONSULTATION DATE ONLINE AFTER COMPLETING THIS FORM.

Thank you!
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Client Intake Form

Treatment + Consent