New Client Intake Form

1
Client's Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
How did you hear about Radiant Jade Ethetics?
4
I will take before and after photos during your session to catalog your results and keep in your file. Do you give permission for me to post treatment photos/videos to my website, business Instagram, and/or my business Google page for marketing and portfolio purposes?* This field is required.
Yes
No
5
Emergency Contact * This field is required.
First Name
Last Name
6
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
7
Which aromatherapy scent would you prefer?
Eucalyptus
Lavender
None
8
Do you have any of the following conditions? If yes, please select them:
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV AIDS
Hepatitis A/B/C
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
I do not have any of these
Other
9
If you selected Other or any of the above conditions, please describe or feel free to add any additional information:
10
Please list any known allergies or skin sensitivities. (i.e.: food allergies, skin allergies, latex, sensitivity to heat, cold, fragrance, etc)* This field is required.
11
Do you smoke?* This field is required.
Yes
No
12
Do you use tanning beds?* This field is required.
Yes
No
13
When you go out into the sun do you (Check one):* This field is required.
Always burn (I)
Usually burn (II)
Sometimes burn (III)
Rarely burn (IV)
Very rarely burn (V)
Never burn (VI)
14
Are you prone to cold sores?* This field is required.
Yes
No
15
Are you pregnant?
Yes
No
16
If yes, what is your due date?
17
Are you trying or planning to be pregnant?
Yes
No
18
Are you currently taking/using any prescription contraceptive pills, implants, etc?
Yes
No
19
Are you breastfeeding?
Yes
No
20
Have you undergone any major surgeries in the last 90 days? If yes, please describe:
21
Have you recently received Botox or dermal fillers?* This field is required.
Yes
No
22
If yes, what and how recent/ how often:
23
Have you recently received a chemical peel, laser treatment, or IPL?* This field is required.
Yes- in the last month
Yes- in the last 2-3 months
No
24
When was your last facial service and what type of service did you receive? (Write N/A if this is your first facial service)* This field is required.
25
Please check any of the following facial treatments you have received:* This field is required.
Dermaplaning
Facials
Microdermabrasion
Chemical Peel
LED Light therapy
High Frequency
Microneedling
IPL/Laser Treatments
Facial waxing/sugaring
Other
26
How many oz of water do you drink daily?* This field is required.
27
Skin condition* This field is required.
Normal
Oily
Dry
Acne
Combination
Other
28
How does your skin heal?* This field is required.
Fast
Pigments
Scars
Slow
29
Do you have a daily skincare regimen? If yes, do you follow your regimen morning, evening, or morning and evening?
30
Please list the skincare products you are currently using and how often:
31
Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any other Vitamin A derivatives?* This field is required.
Yes
No
32
Please list any prescription, OTC, or vitamins and supplements you are currently taking:
33
Do you have any of the following skin concerns (Check all that apply):
Fine lines and wrinkles
Acne scarring
Redness
Hyperpigmentation, sun spots, Melasma
Rosacea
Sensitivity
Loose, sagging skin
Dull/Dry skin
Excessive oil/ shine
Dark circles
Acne
Clogged pores/blackheads
Rough uneven texture
Uneven skin tone
Broken capillaries
Other
34
What are your goals for your skin? * This field is required.
35
Do you currently have any open wounds or active cold sores/ fever blisters on the treatment area?* This field is required.
Yes
No
36
If yes, please describe:
37
Do you currently have sunburned, windburned, extremely dry, chapped or irritated skin?* This field is required.
Yes
No
38
If yes, please describe:
39
In the last two days have you received facial waxing, skin care facial, or laser hair removal?* This field is required.
Yes
No
40
If yes, please describe:
41
In the last 2 weeks have you used any topical and/or oral prescription strength medications such as Retin-A, Tretinoin, Adapalene, Differin, Renova or similar, received Botox, injectables, or dermal fillers, received dermaplaning or microdermabrasion?* This field is required.
Yes
No
42
If yes, please describe:
43
In the last two weeks have you received a chemical peel, microneedling, or microblading?* This field is required.
Yes
No
44
If yes, please describe:
45
In the last month have you received IPL?* This field is required.
Yes
No
46
In the last 6 months have you undergone chemotherapy, radiation, used Accutane, or undergone laser or cosmetic surgery?* This field is required.
Yes
No
47
If yes, please describe:
48
I understand, have read, and completed this form truthfully.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I understand that my information is strictly confidential.

I give consent for treatment.

I acknowledge that the esthetician holds the right to terminate the session at any time.

I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable.

I will inform my esthetician of any discomfort I may experience at any time during my treatment to allow her to adjust accordingly.

I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received.

I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I understand that it is my responsibility to inform the esthetician of my current medical or health conditions, and to update this history as needed.

The treatments I receive here at Radiant Jade Esthetics are voluntary, and I release Radiant Jade Esthetics, and Vanessa Lines, Licensed Esthetician from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.
49
Terms and Conditions* This field is required.
50
Client Signature
51
Date Signed
Date
Month
Day
Year
Should be Empty: