Client Intake Form
Please fill out the following:
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Policies:
printing name is signing
I understand that the services are not a substitute for medical care; and any information provided by an esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential.
*
First Name
Last Name
SOCIAL MEDIA CONSENT: Do I have consent to post any photos or videos on any social media platform that I take during your appointment?
*
First Name
Last Name
CANCELLATION PROTOCOL: We request a minimum 48 hour notice for cancelations for any scheduled appointment. 20% of your scheduled services will be required without a 48 hour notice. Same day cancelation, or no call no show will result in 80% fee of your scheduled service.
*
First Name
Last Name
LATE POLICY: As a courtesy please call or text me if you are running 5-10 min late. If you are running 15 min it will result as a now show and you will be charged a a no show fee (please read the third paragraph)
*
First Name
Last Name
CHEMICAL PEEL CONSENT: My esthetician may choose to use a surface peeling chemical exfoliant during my facial and I give consent
*
First Name
Last Name
CONSENT TO TREAT A MINOR: Please print guardian/parent name. If not a minor just print name. I hereby authorize all service providers to administer esthetic, massage, reiki services to my child or dependent, as deem necessary.
*
First Name
Last Name
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Facial Form
If receiving a facial please fill out the form below:
Is this your first facial?
Yes
No
Are you presently under a physicians care for any current skin condition or other problems?
Yes
No
Are you pregnant?
Yes
No
Maybe
Are you taking birth control?
Yes
No
Are you presently using (or used in the past) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids (AHA)?
Yes, But not recently
Yes, In the last 6 months
No
Are you now using or have you ever used Accutane?
Yes, In the last 6 months
Yes, But not recently
No
Do you smoke?
Yes
No
Have you had skin cancer?
Yes
No
Please list any allergies to cosmetics, foods, or drugs (shellfish, iodine, gluten, soy, sulphur, seasonal, nuts)?
What skincare products do you use presently?
Have you ever had an adverse reaction to a skin care treatment? if yes, please describe.
Have you had a chemical peel, laser or microdermabrasion treatment in the last 6 months?
Yes
No
Do you tan? (tanning booth or outdoor uv exposure)
Yes
No
Please check if you are affected by any of the following:
Asthema
Cardiac Problems
Depression
Herpes
Fever Blisters
Headaches
Anxiety
Epilepsy
Hysterectomy
Skin Disease
Hepatitis
High Blood Pressure
Claustrophobic
Sinus Problems
Immune Disorders
Lupas
Pace Maker
Eczema
Metal bone, pins, plates
Psoriasis
List any other significant problems:
Wax Form
If you are receiving a waxing please complete the form down below:
Have you taken Accutane within the past 6 months?
Yes
No
Are you taking Retin-a, Differin, or Renova?
Yes
No
Are you taking any medication that would make your skin sensitive?
Yes
No
Are you currently Sunburn?
Yes
No
If you have any medical conditions that could effect your skin during the waxing services, please list below:
Are you using any of the following Medications YOU CAN NOT BE WAXED TODAY
Accutane
Renova
Tretinoin
Adapalene
Alustra
Isotrentinoin
Avita
Differin
Retin-a
Tazarotene
CONSENT AND SIGNATURE: I UNDERSTAND THAT IF I BEGIN USE, OR ARE CURRENTLY USING, ANY OF THE PRODUCTS LISTED IN THE ABOVE WARNING AND DO NOT INFORM THE ESTHETICIAN PRIOR TO CURRENT OR FUTURE TREATMENTS, I ACCEPT FULL RESPONSIBILITY FOR ANY ADVERSE REACTIONS. I UNDERSTAND THAT WAXING MAY CAUSE SOME REDNESS, BUMPS, SORENESS, AND/OR ITCHING. (printing is signing)
First Name
Last Name
Should be Empty: