Hey Beauty...
Please take a moment to fill out this form, all questions are required to be filled out in order to move forward with your service (if there's no suitable option, select N/A, or skip to the next question). This client intake form is to help me get to know you, and your skin, on a deeper level so we can better approach your overall goals and purpose for today's visit. Otherwise, any other questions, concerns, requests please mention them to your Esthetician to ensure I'm able to accommodate your service to the best of my ability. Please note, all written and verbal discussion between Esthetician & client(s) is strictly confidential.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about Charismatic Beauty?
If applicable, name of person who referred you:
General Health
Do you participate in any physical activities? (i.e. weight-lifting, swimming, hiking, yoga, etc.)
How much sun exposure is received?
Please Select
Minimal
Moderate
Above Average
Do you wear contact lenses?
Please Select
Yes
No
Please list any known allergies:
Medication (ex: Aspirin)
Material (ex: Latex)
Food (ex: Seafood, Nuts, etc.)
Other (ex: Seasonal, Cyanoacrylate)
Do you experience any skin sensitivity?
Redness/ Rosacea
Breakout/ acne prone reaction(s)
Reaction(s) to certain products/ ingredients (irritation, burning sensation)
Do you consume alcohol, if so, how much/ often?
Please Select
Minimal
Moderate
Above Average
None
Do you smoke, if so, how much/ often?
Please Select
Minimal
Moderate
Above Average
None
Please list any Medication(s)/ Supplement(s) if currently taking any:
Are you currently taking:
Antibiotic
Birth Control
Blood Thinners
Hormone Replacement
Other
Please check all that may apply
Metal Implant(s)
Pace Maker
Body Piercing(s)
Health History
Please check all that may apply:
Arthritis
Irregular Digestion
Herpes Simplex Virus
MRSA
Allergy to Iodine or Shellfish
Circulatory Problems
Hypertension
Eye Infection/Disorder
Chronic Pain
Osteoporosis
Sleep Problems
Varicose Veins
Heart Disease
Epilepsy
Serious sun burn or exposure
Diabetes
Claustrophobia
Eczema
Psoriasis
Sciatica
Hyper/ Hypo- thyroid
Facial warts
Headaches
Keloid/ Hypertrophic scars
Sun Allergy
None- n/a
Have you been diagnosed with Cancer
Please Select
Yes
No
If yes, please fill out an Oncology Intake form.
Are you pregnant/ nursing, or trying to become pregnant?
Please Select
Pregnant
Nursing
Trying to become Pregnant
None- N/A
Reason for your visit today
Relaxation
Stress Reduction
Headache
Escape
Health/Wellness
Other
Skin Care
Are you under the care of a Dermatologist?
Please Select
Yes
No
Do you use any of the following?
Accutane
Retin-A
Renova
Adapalene
Resorcinal
Scrub or Peel
Other prescription product(s)
N/A
Have you had any of the following
Chemical Peel
Microdermabrasion
Botox
Dermal Filler
Permanent Cosmetics
Other Resurfacing Treatment(s)
Lash Extensions
Lash Lift
Brow Lamination
Lash/ Brow Tinting
Any serious side effects?
Please Select
Yes
No
Are you currently using any of the following?
Glycolic
Lactic
Hydroxy Acid
Vitamin A
Vitamin C
N/A
Skin Maintenance
Skin type
Normal
Combination- both oily, and dry
Oily/ Congested
Dry/ Dehydrated
Sensitive
Acne
Sunburned
Have you been tanning in the last 24 hours?
Please Select
Yes
No
In the last week have you had:
Waxing
Electrolysis
Products Used- List Brand & Frequency of Use
Facial Cleanser(s)
Toner(s)
Exfoliant(s)
Facial Mask(s)
Serum(s)
Moisturizer(s)
SPF
☆By signing below, I acknowledge that I understand and accept the Charismatic Beauty Privacy Policy, which can be found online at www.charismaticbeautyaz.com.It is my choice to receive beauty treatments, including facials, skin care, hair removal, microdermabrasion, chemical peels, Ultrasonic, LED, cosmetic lash/brow services. If at any time, for any reason, I want the service to end, I will ask, and my service provider will cease the service immediately. Because facials, skin care and other beauty treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I will update Charismatic Beauty of any changes to my health status. I understand that Estheticians do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during the session, I will immediately inform my Esthetician so that the service may be adjusted to my level of comfort or discontinued. I could experience varying degrees of redness, burning, peeling, itching, etc., especially in the initial stages of a skin care program. I further understand that I am paying for a treatment and not a result and that there will be no returns, refunds or exchanges.
Agree
☆I agree if I am unable to make it to a scheduled appointment, to cancel the appointment 24 hours in advance, by phone unless I have an emergency. In this case, I will call ASAP to reschedule my appointment. If I miss a scheduled appointment without giving a 24 hour notice, I agree to pay the missed appointment fee (50% charge of service ticket) that applies.
Agree
☆I understand that any illicit or sexually suggestive behavior, remarks or advances made by me will result in the immediate termination of the session and I will be liable for payment of the scheduled service. Further, I understand that Charismatic Beauty and the Esthetician providing the service reserves the right to refuse to administer services at any time at their sole discretion. I have read and fully understand this form in its entirety.
Agree
I understand should the service I am/may be receiving call for me to undress to my level of comfort, my Esthetician can perform an effective service regardless of my level of undress, including continuing to wear undergarment(s). I will allow my Esthetician to discuss any instructions prior to my service, and wait to undress until my service provider has exited the room. I understand client comfort & safety is the main priority, and am in good hands with Charismatic Beauty.
Agree
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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