• Client Intake Form

    Client Intake Form

    " Always love yourself"
  • Date of Birth*
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  • Medical History

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

  • Do you currently take any medications?*
  • Do you have any allergies? (food, latex, plants, etc)*
  • Skin type:*
  • What are your skin concerns:*

  • Terms & Conditions

  • 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.
  • Date Signed*
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  • Client Consent & Liability Waiver

    Client Consent & Liability Waiver

  • I, *   *      *    

    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 there is 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 me.

    If provided with pre- and/or post-treatment instructions, I will adhere to the given regimen. I certify that 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.

    The information I have provided regarding my medical history is accurate to the best of my knowledge, and I affirm I do not have any ailments or conditions that would make this treatment/procedure incompatible with my health and wellbeing.

  • 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 Amate Beauty LLC, not liable for any damages, injuries, or claims that may result from this treatment/procedure.   

  • Date*
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  • Use of Treatment Records, Photographic Images, & Video Consent

    Use of Treatment Records, Photographic Images, & Video Consent

  • I,                   Amate Beauty LLC, to use such photographs and/or videos for educational/training purposes, informational presentations, social media related platforms, promotional materials, marketing purposes, or for the illustration of books.

    I understand that I will not be entitled to any payment, royalties, or other forms of compensation as a result of any use of the photographic images/videos/audio, and/or testimonials of my treatment(s) or procedure(s), and/or interviews concerning those treatment(s) or procedure(s).

    I further understand that this material may be distributed in all forms of both print and digital media.

    I fully understand the purposes in which my images and/or videos may be used, and I am willingly allowing Amate Beauty LLC, 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 Amate Beauty LLC.

    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.

  • Date*
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