• Client Consultation & Consent Form

    Please answer these questions to help provide the best service for your skin. This information is used to evaluate your individual skincare needs. All responses and information will be maintained confidentially and will not be provided to anyone else, except as required by law.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • How did you hear about us?*

  • Your Medical History

  • Are you currently under the care of a physician?*
  • Have you experienced any health conditions in the past or present?*

  • Any known allergies?*

  • Have you ever experienced claustrophobia?*
  • Are you pregnant or breast-feeding?*
  • Please select all that apply to you.*

  • Your Skin

  • What would you say your skin type is?*
  • What skin care products do you use on a daily basis?*

  • Are you currently using any exfoliating or Vitamin A products?*

  • Do you experience any breakouts or acne?*
  • Do you experience redness, itching, or stinging on your skin?*
  • Have you been diagnosed with eczema, psoriasis or rosacea?*
  • Have you received Botox, fillers or other injectable procedures within the last two weeks.*
  • Have you received any facial hair removal services in the last 7 days?*

  • Have you used a prescription for a skin concern in the last 6 months? Have you used any of the following for something other than a skin concern in the last 6 months?*
  • Have you ever received laser services, IPL, etc. treatments?*
  • Have you ever received chemical peels, microdermabrasion or any other resurfacing treatments?*
  • When was your last facial?*

  • I acknowledge that my skin might experience temporary irritation, sensitivity, tightness, redness or slight swelling which usually dissipates within 72 hours after treatment(s), depending on skin sensitivity.

    I acknowledge that in some cases there may be complications, irritation and allergic reactions and understand the risk of undergoing the treatment and all future treatments.

    I acknowledge that if I fail to properly use a minimal sunscreen of at least SPF30, I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10AM-2PM.

    I acknowledge that this treatment and all future treatments are strictly elective cosmetic procedures and no medical claims have been expressed or implied.

    I acknowledge and understand that individual treatment results may vary.

    I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended after care or home regimen for 1-4 weeks following this treatment and all future treatments.

    I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

    I release and waive any claims against Skincare Habit for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in my treatment, and all future treatments, including but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Skincare Habit.

  • Social Media Photo Release

  • I hereby agree and consent as follows.

    I consent and authorize Skincare Habit, located at 304 1st St. Liverpool, NY 13088 to use my likeness in any photograph, video or other digital media (“Photos”) in any and all of its publications, including print or web-based publications.

    I irrevocably authorize Skincare Habit to copy, edit, enhance, crop, or otherwise alter any Photo for use in their publications. I also waive any rights for approval or inspection of any Photos.

    I understand and agree that all Photos are the property of Skincare Habit, and will not be returned to me.

    I acknowledge that I am not entitled to any compensation or royalties with respect to the use of the Photos.

    I agree to release and forever discharge Skincare Habit and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them, in their individual and/or corporate capacities from any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any nature or kind, known or unknown, which I, and anyone claiming on behalf of me, may have or claim to have against Releasee in connection with this Release.

    I have carefully read and fully understand all the provisions of this Photo Release Form and am freely, knowingly and voluntarily signing.

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