Intake Form (FACIAL SERVICES ONLY)

Client's Name

First NameLast Name

I hereby consent to and authorize BARE ESTHETICS BY RANTE to perform the following procedure(s):

Gender

Other

Date of Birth

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

Do you have any of the following conditions? If yes, please select them:

Have you undergo any surgeries?

If yes, please explain.

Please list any allergies.

Please list any/all medications you are currently taking.

Is this your first facial?

Which of the following best describes your skin?

Have you had any facial or dermatology services in the past 30 days?

How does your skin heal? (Check all that apply)

What are your skin care concerns? (Check all that apply)

How do you take care of your skin at home?

What beauty or cosmetic products are you currently using?

Do you currently have any cold sores/blisters? (If yes, you will need to reschedule your treatment)

Do you consume alcohol?

Do you smoke?

Are you pregnant?

Are you taking any contraceptive pills?

Are you breastfeeding?

Do you consume caffeinated drinks?

Are you currently under any kind of diet?

Do you wear any contact lenses?

Are you using any of the following products or ingredients orally or topically? (Check all that apply)

If you selected any of the options above, please complete.

Have you had chemical peels, enzymes, microdermabrasion, dermaplaning, or laser done within the past 30 days?

Other

Do you receive Botox, fillers, or any injections?

If yes, what/when was your last treatment?

Any additional concerns that you would like me to be aware of?

How'd you hear about us? (If you were referred, please leave their name and phone number.)

Do you consent to photos/videos during your service? (All photos/videos will be used on Instagram, @__bareesthetics, for promotional and educational purposes)

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my skin care professional and/or the salon for any injury or damages incurred due to any misrepresentation of my health.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me.

I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.

I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understood the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the esthetician, BARE ESTHETICS BY RANTE, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.

Client Signature

Date Signed

Date

Intake Form (FACIAL SERVICES ONLY)

Terms & Conditions