Client Intake + Consent Form
Roseanna Drake Aesthetics
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
*
Are you currently taking any medications?
*
Yes
No
Please check if you are affected by or have any of the following or check the "None" box:
*
Anemia
Hemophilia
Cancer
HIV/AIDS
Pace Maker
Herpes Simplex (cold sores)
Psoriasis
Staph Infection
Eczema
Rosacea
Hormone Disorder
NONE
Please list any allergies you have:
*
Are you currently pregnant, nursing, or trying to conceive?
*
Do you use birth control pills, shot, or IUD? Please list what kind!
*
Please list all skincare products you are currently using!
*
Have you ever had an adverse reaction from a product or treatment on your face? If yes, please explain:
*
What are your current skin concerns and skin goals?
*
Have you received facial waxing, botox or filler within the last two weeks?
*
Have you been on accutane in the last 6 months?
*
Do you see a dermatologist?
*
Do you prefer a silent appointment?
*
Yes
No
No preference
Are you okay with photos/videos being posted of your service for marketing?
Yes
No
Yes, but block out eyes
Terms, Conditions, and Liability
I have accurately answered the above questions to the best of my knowledge including all known allergies, prescriptions, skin conditions, and products I am currently ingesting or using topically. I will be sure to ask questions and let my esthetician, Roseanna know of any possible concerns before my appointment. I understand my skin care specialist will take every precaution to minimize or eliminate any negative reactions as much as possible and be thorough. By signing this I hold my skin care specialist, Roseanna, harmless and nameless from any liability that may result from this treatment.
I agree to the terms and conditions:
*
POLICIES!
A card is required to be on file for all clients. You must cancel your appointment within 24 hours of your scheduled appointment time. If you reschedule or cancel within less than 24 hours notice, a charge of 50% of the service you booked will be charged to the card on file. If you no-show, you will also be charged 50% of the service you booked. No-shows are unacceptable. If a client no-shows more than once, they may be denied booking in the future or will have to pay a 50% deposit of their service before booking. If the card declines, fees must be paid before another appointment can be booked/accepted. If you are 15 minutes late to your appointment, your service will still end on time and you'll be charged the full service fee. If you are more than 15 minutes late, you may be asked to re-schedule and also be charged 50% of the service you booked. Please plan ahead and take traffic into consideration. I must stay on schedule out of respect for my other clients designated time. Clients under the age of 18 are required to have a parent/guardian signature and parents are encouraged to be present during the time of their appointment. Failure to comply to any policies listed will result in clients not being able to book future appointments. Thank you for your understanding!
I understand and agree to the policies:
*
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