Client Intake Fanm

• Acne   
• Fever   

• Bleeding Disorder  / 
• Cancer/  Chemotherapy/ Radiation
• Cardio/Vascular Issues

• Fungal Condition  /  Headaches/ Migraines
• Heart
• Liver/ Kidney Disease
• Skin Cancer  /  Skin Conditions/ Disorders
• Stress
• Organ Failure  
• P lastic/  Bone Cement/ Metal Implants
• Pre-Cancerous Lesions
• Pregnant/Breast Feeding
• Depression
• Easily Bruises/ Sensitive Skin
• Hives/Herpes/Shingles
• Hyper/Hypo Thyroid Hypertension
• Recent Surgical Incisions
• Respiratory Conditions
• Watery Eyes/ Seasonal Allergies

Are you currently taking any medications?

Do you smoke or consume alcohol?

Please describe your skin type:

Have you had any facial or dermatology services in the past 30 days?

Have you used any Bleaching, Retin-A, AHAs or Retinol/Vitamin A products in the last 90 days?

Have you had any Botox, Restylane, Juvederm or Collagen injections within the last 6 months?

Any history of Accutane (isotretinoin) use?

Do you frequently use tanning beds or have had any excessive sun/UV exposure within the last 4 weeks?

Please list the products you are currently using in your skin care routine: Be as specific as you can with the brands/names/ingredients.

 

• Acne
• Blackheads
• Broken Capillaries
• Comedones
• Cherry Anginoma
• Discolorations
• Dryness/DUllSkin
• Eczema
• Fine Lines Wrinkles
• Hyperpigmentation
• Hypopigmentataion
• Keloids
• Milia
• Oly Skin
• Psoriasis
• Redness
• Rosacea
• Scarring
• Sensitivity
• SunDamage
• Thin
• Unwanted Hair
• Other______

 

Would You like to be add to ur email list for special and discounts? __ Yes __No

How did you hear about us? _____________________________________

I understand that this form and it's data are completely confidential, The information Thave provided regarding my medical history is accurateto the best of my knowledge, and affirm do not have any aliments or conditions that would make this treatment/procedure incompatible with my health and wellbeing. By signing this form,1 certify that am at least 18 years of age and fully competent to give my consent; that have been given the opportunity to ask any questions may have, and those questions have been answered - acknowledge the information given to me pertaining to the requested treatmentis)procedure(s), and have been sufficiently informed of the benefits and risks involved agree to inform my Esthetician/Technician if experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. - agree to waive all liability towards my Esthetician/Technician : and Trinity and Company, for any possible harm or injury in the case of my failure to disclose any and all/past and present health conditions

____________I am fully aware that my condition is of cosmetic concern, and that the decision to proceed is based solely on my expressed desire to do so. I understand with any treatment/procedure there isa possibility of short term effects, as well as rare side effects, and all of the effects pertaining to this treatment/procedure have been fully explained to me.

____________I confirm that I am not pregnant or breastfeeding at this time, and that I have not taken isotretinoin (also known as Accutane) within the last three months. I have also completed a medical history checklist, and have been informed about what I "must do" and "not do" before, during, and after the treatment/procedure.

____________I understand that there is no guarantee of results with any treatment/procedure, and that thereis always some risk involved, albeit small. Clinical results may vary depending on individual factors, including age, medical history, amount of sun damage, textural problems, skin type, client compliance with pre-/post-treatment instructions, and medications taken. I understand that it is possible that more than one treatment may be necessary to achieve the desired effects, and the fee structure has been fully explained to

___________If provided with pre- and/or post-treatment instructions, I will adhere to the given regimen. I certifythat I have been fully informed of the nature and purpose of the treatment/procedure, expected outcomes, and possible complications I understand that no guarantee can be given as to the final result obtained If I was given a pre-treatment protocol, I assert I have followed the plan carefully and fully.

________The Esthetician/Technician has explained the nature of my condition, the nature of the treatment/procedure, and the benefits to be reasonably expected compared with alternative approaches, including the likely results of not preforming the treatment/procedure. The Esthetician/Technician has discussed the likelihood of any risks and complications of this treatment/procedure. The Esthetician/Technician has also indicated that with any procedure there is always the possibility of an unexpected complication.

By signing this form, I certify that I have read and fully understand the contents of this consent form, and I have been sufficiently informed of the benefits and risks involved with treatment; that I am at least 18 years of age, and fully competent to give my consent. I acknowledge I have been given the opportunity to ask any questions I may have, and those questions have been answered. I duly authorize the Esthetician/Technician to preform the above specified treatment for me, as well as any post treatment requirements that may be necessary. I understand my Esthetician/Technician will take every precaution to minimize or eliminate negative reactions as much as possible, and I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. I agree to hold my Esthetician/Technician and Trinity and Company, not liable for any damages, injuries, or claims that may result from this treatment/procedure.

I , hereby authorize Trinity and Company , to take, alter, edit, exhibit, distribute, and publish my photographic images/videos/audio and/or testimonials for lawful promotional materials, as well as to enhance the documentation of my treatment record. I agree that these photographic images/videos/audio and/or testimonials well remain the property of Trinity and Company. I understand that this material may be used, reproduced, published, or republished and if, in the judgment of my Esthetician/Technician education/instructional courses and science will be benefited by their use for any or all of the following purposes including but not limited to: educational, training, or teaching purposes, newspaper release, professional journals, brochures, advertisements, branding kits/packages, websites, social media platforms, video, digital applications and other sorts of electronic distribution.

I fully understand the purposes in which my images and/or videos may be used and I am willingly allowing Trinity and Company, the use of my photographic images/videos/audio and/or

testimonials. Consent encompasses all photographic images/videos/audio, testimonials, interviews, and/or data obtained by Trinity and Company.

This consent is hereby valid indefinitely from the date in which it is signed There is not any geographic limitation to where these materials may be exhibited, published, or distributed

By signing this form, I certify that I have been given the opportunity to ask any questions I may have, and those questions have been answered I acknowledge I have read and fully understand the contents of this consent form, and that I am at least 18 years of age, and fully competent to give my consent.

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions of which Trinity and Company, adheres to comply, along with increased sanitation and disinfecting practices within our facility. Please complete the following checklist and sign below.

I confirm that I. including members within my household, have not experienced any of the following symptoms within the last 14 days:

Headache New loss of taste or smell Sore throat

Congestion or runny nose Nausea or vomiting

To the best of my knowledge I, including all members within my household, have not recently tested positive, or been in contact with anyone who has tested positive for COVID-19 within the last 14 days. (initial)

I verify that I, including all members within my household, have not traveled internationally in the past (initial) 30 days.

Due to the nature of the service/treatment/procedurel will be receiving today, I understand that social distancing of at least 6 feet, as recommended by the CDC, is not possible. (initial)

I am fully and personally responsible for my own safety and actions during my service/treatment/procedure, and I recognize that may be in any case at risk of contracting COVID-19. (initial)

Iagree to hold Trinity and Company]. not liable for any and all cost, expenses, damages, lawsuits and/or liabilities that may arise from direct, indirect, or in relation to any and all claims made by or against any of the released party due to injury. loss, or death from or related to COVID-19. (initial)

By signing this form, I certify that I have been given the opportunity to ask any questions I may have, and those questions have been answered I acknowledge I have read and fully understand the contents of this waiver, and I have been sufficiently informed of the risks involved. I certify am at least 18 years of age, and fully competent to give my consent. I agree to hold Trinity and Company, harmless from any and all liability for the unintentional exposure, harm, damages, or risks involved due to COVID-19.