Client Intake/Consent Form

ALL CLIENTS MUST FILL OUT THIS FORM BEFORE YOUR FIRST APPOINTMENT
Skin Karma Client Intake/Consent Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
Birth Date*
Phone Number*
Medical / History Data
Are you pregnant, breastfeeding, or nursing?*

YesNo
Are you currently taking any prescribed medications (such as acne medications/anything from a dermatologist, etc)? If yes, please list them below:*
Do you have any known allergies/skin sensitivities? Please list:*
Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any Vitamin A derivatives?*

NoYes
If so, how recent/ how often?
Have you recently received Botox/ Dermal Fillers?*

NoYes
Have you recently received a chemical peel or laser treatment?*

NoYes- in the last monthYes-in the last 2-3 months
Did you undergo any major surgery in the past 90 days? If yes, please describe:
Authorization

By submitting and signing this form, I acknowledge, and consent to the following:
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments. I acknowledge that Glennda Rios/Skin Karma holds the right to terminate the session at any time. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I release Glennda Rios/Skin Karma from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof. In the event a dispute arises over the outcome of my procedure I consent solely to arbitration as a legal means of settlement. I understand English or if I do not, I have appointed someone to translate this consent form in its entirety.
Signature*

First NameLast Name
Photographs

I give permission for photographs to be used by Skin Karma for educational and promotional purposes. Complete patient confidentiality will be maintained at all times. *Please initial *
Initial here
Should be Empty:

Skin Karma Client Intake/Consent Form

Medical / History Data

Authorization

Photographs