Client Intake/ Release Form

Client Intake/ Release Form
Client's Name

First NameLast Name
MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
NormalOilyDryAcneOther
FastPigmentsScarsSlowOther
How do you take care of your skin at home?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. AG esthetics 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 provider will not be liable.

I release the provider and hold harmless against any claims, expenses, damages, and liabilities.

I release any photo rights to any photo taken while in service.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Terms & Conditions