Radiant Skin and Brows - New Esthetics form

Radiant Skin and Brows

New Client Intake and Consent Form
Name*

First NameLast Name
Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Occupation
How did you hear about us?
How would you describe your skin?

DryNormalOilyCombinationSensitive
What are the top 2-3 things you would like to focus on?

Aging (fine lines/wrinkles)Stress reduction / relaxationAcne / breakoutsRedness / inflammationCongested pores (white/black heads)Dullness / drynessSun damage / hyperpigmentation / dark spotsExcessive oilinessOther
What skincare products do you use? (please include full product name, if possible)
Please check all that apply regarding your medical history.

Pregnant / breastfeedingHormonal birth controlBleed / bruise easilyCancer (please explain below)DiabetesEpilepsyCold sores (please reschedule if you have active lesions at time of appt)Any diagnosed skin condition (eczema, psoriasis, rosacea)Treated by a dermatologist within the last year (please explain below)Contact lensesPacemaker or other implanted medical deviceMetal pins, plates, etcSensitive to pressure or heatHIVHepatitisClaustrophobiaCirculatory issuesAutoimmune disordersTaken Accutane within the last 6 monthsRecent Botox/filler (within 2 weeks of appt)Other recent skin treatments (lasers, chem peels, microneedling, etc)History of sensitive skin (any specific reactions?)Use of Vit A/retinoids (retinol, tretinoin, adapalene, etc)
Please explain any items you checked above, and list current oral/topical medications, as well as recent surgeries.
Any allergies? (Including foods, cosmetics, medicines, etc)
Sun Exposure (current/past? frequency? Tanning bed use?)
If receiving a facial, do you prefer a more quiet, relaxing service, or would you like me to explain what I'm doing and what products I'm applying?

I just want to relax!Give me all the education please!Quiet during the services, but explain after!No preference
Photo Release - Some services require before/after photos for insurance, but do I have your permission to post photos or videos taken during your service for promotional or educational purposes?*

YES, feel free to use themNO, I'd prefer you didn't
Reminders and Policies:

Cancellations within less than 24 hours (or if you are over 20 min late) will be charged a fee of 50% of the service. No call/no show appointments will be charged 100% of the service.

I can accept cash, card, or venmo. Payment must be made before leaving your appointment. There are no refunds of services rendered or products purchased.

Please do not bring any children or guests who are not also receiving a service (unless you have spoken to me)

Please put cell phone on silent, so you can be present for the appointment, especially facials!!

For facials, please wear little to no makeup to your appointment. If you have much makeup on, removing your makeup will take time away from your skin treatment.

For any facial or waxing service, avoid use of any retinoid (vit. A, tretinoin, retinol, adapalene, etc) or exfoliating acids (glycolic, lactic, salicylic, etc) for at least 5 days prior.

- I confirm that the answers I have given are correct to the best of my knowledge and I have not withheld any information that may be relevant to my treatment.

- I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate.

- I hereby consent to and authorize Rachel Farmer to perform the esthetic services I have voluntarily elected to undergo.
I have read and agree to the above policies and statements.*
Please Initial
While Radiant Skin and Brows takes reasonable precautions to minimize the likelihood of any personal injury resulting from the provision of esthetic treatment services, there is inherent risk involved in the delivery and receipt of skincare treatment services, which risk cannot be completely eliminated. By signing below, I acknowledge the existence of this risk, and I agree to accept and assume this risk. I further acknowledge that it is my responsibility to ask questions about the services, to disclose all known allergies and medical conditions to the service provider, and to make an informed decision regarding the receipt of services, all prior to receipt of any services.*

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