Signature Facial Medical Intake and History

  • Client Questionnaire

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Okay To E-Mail?
  • Okay to Call?
  • Okay to Text?
  • Format: (000) 000-0000.
  • Do we have permission to show your non-identifying photos for social media purposes?
  • How did you hear about Estie Co.?

  • Medical History & Intake

  • What concerns you most about the overall appearance of your skin? (check all that apply)
  • How would you describe your skin?
  • How would you describe your stress level?
  • Do you feel your stress level may be affecting the health of your skin?
  • Are you in good health overall?
  • Are you currently under the care of a physician?
  • Do you have any of the below health issues?
  • Do you have any allergies to foods, skincare ingredients, or medications?
  • Have you ever experienced a reaction to any of the following?
  • Are you currently on any medications either topical or oral? (i.e Accutane, antibiotics, birth control)
  • How do you heal after an acne breakout, cut, or scratch?
  • Do you smoke?
  • Are you prone to cold sores? (Treatment cannot be completed if the client has an active cold sore. Client must wait until the cold sore is completely healed before scheduling a treatment.)
  • Do you tan in tanning beds/booths?
  • Does your job and lifestyle require that you work/play outdoors?
  • Rows
  • Rows
  • Do you wax your facial skin on a regular basis?
  • Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments?
  • Have you received Botox, Juvederm, or other dermal fillers within the last two weeks?
  • Please check the skincare products you are currently using:
  • Are you Vegan?

  • I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company (Estie Co. LLC)  and/or skin care professional from liability.

  • Date
     / /

  • Client Policies

  • Estie Co. will now require 24 hours notice for rescheduled and canceled appointments.There will be a 50% charge of service booked for last-minute (within 24 hours) cancellations or reschedules.

     

    90% of the service booked will be charged for no-call/no-shows. This will need to be paid before you are allowed to book another appointment. Refusal to pay will result in a ban from my schedule.

     

    If you are running 15+ minutes late for your appointment, there will be a 50% charge of the service booked and the appointment will need to be rescheduled.

     

    Sickness: Please, please do not come to your appointment if you are feeling sick AT ALL. Reschedule your appointment for a later date. This keeps everyone safe and allows Jules to continue working. There will be no exceptions for this, if you are sick, you will be sent home and charged 90% of the service.

     

    You can easily reschedule your appointment by going to the link that is sent to your email when you book. We know that last-minute things pop up so please make sure you reach out when canceling/rescheduling.


     
    By signing below, I am agreeing to the policies stated above and agree to pay any penalties that may be charged by Estie Co. LLC in accordance to these policies.

  • COVID-19 Information & Liability Waiver

  • 1. Have you had a fever in the last 24 hours of 100°F or above?
  • 2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
  • 3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus type symptoms?

  • COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected. 


    Consent for Treatment 

    I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

  • Date
     - -
  • Should be Empty: