New Client Intake Form + Liability Waiver

1
Name:* This field is required.
First Name
Last Name
2
Phone Number:* This field is required.
Please enter a valid phone number.
3
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Birthday:* This field is required.
Date
Year
Month
Day
5
Emergency Contact Name:* This field is required.
First Name
Last Name
6
Emergency Contact Phone* This field is required.
Please enter a valid phone number.
7
Emergency Contact Relationship:* This field is required.
8
How did you hear about Trentuno Skin Studio? Were you referred by someone?optional
9
Medical History:* This field is required.
Diabetes
Skin cancer or other type of cancer
Cold sores or fever blisters
Epilepsy or seizures
Migraines
Skin infections
High blood pressure
Heart disease
Autoimmune disease
Bleeding Disorder
None of the above
10
Do you have any allergies to any medications or topical products that you know of?* This field is required.
YESNO
11
If yes, what allergies?
12
Do you have any type of neck injury that your service provider should be mindful of during the massage portion of the facial?* This field is required.
YESNO
13
Are you claustrophobic?Some facials include warm towels being wrapped around the face and facial steaming to open pores that make some people claustrophobic. If this applies to you, please let me know so I can modify the service to make you as comfortable as possible!
YESNO
14
Are you currently taking any prescription medications?* This field is required.
YESNO
15
If yes, what medications?
16
Are you currently pregnant?* This field is required.
Yes, I am!
No, I am not.
I’m trying to get pregnant.
I’m not quite sure…
17
Are you currently taking or have been on birth control over the past 6 months?* This field is required.
YESNO
18
What are your goals for this appointment? Do you have any specific concerns you would like to address?
19
Have you ever had a professional facial or beauty treatment before?
YESNO
20
Have you received any injectables like Botox, Juvéderm, or any dermal filler in the last 3 months?* This field is required.
YESNO
21
Have you had any facial or eye surgery within the past 9 months?* This field is required.
YESNO
22
Current skincare routine:Optional field if booking a lash, brow, or waxing service.
I don’t have a routine.
I’m open to suggestions!
Cleanser
Toner
Exfoliator
Mask
Moisturizer
Serum
SPF
Eye cream
23
Skin history or current skin concerns:Optional field if booking a lash, brow, or waxing service.
Redness
Acne
Hyperpigmentation
Scarring
Finelines or wrinkles
Blackheads and/or pimples
Uneven tone and texture
Melasma
Enlarged pores
Rosacea
None of the above
24
Do you like a silent or conversation appointment?
I would like silence, please.
Let’s chat! :)
A mix of both.
25
What level of pressure would you like during your facial?
Light
Medium
Firm
26
Liability Waiver* This field is required.I (client name), agree to having to undergo this treatment/procedure after having the treatment details and nature of the treatment along with risks and hazards involved by qualified and licensed esthetician. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle factors and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment aftercare instructions. I understand how important it is to follow all aftercare instructions given to me. 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 understand and agree to the after-care instructions, provided by the licensed esthetician. I realize and accept the consequences of failure to adhere to these instructions may cause no to little results obtained.
Clear
27
I, (client name) hereby give permission to Victoria Vance, LE at Trentuno Skin Studio to use any photos, videos, or audio that are taken of my service to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications. * This field is required.
YESNO
28
Hold Harmless Waiver* This field is required.I have read and understand this agreement and all information detailed above. I understand the procedure and accept the risks associated with it. I acknowledge that I have been informed of the risks associated with this procedure and have had the opportunity to ask my provider any question regarding this. I understand how important it is to follow all instructions given to me for post-treatment or suggested home product/post - treatment care, I will consult the esthetician immediately if any adverse reactions occur. 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 taking. I also agree to defend, indemnify and hold harmless Victoria Vance, LME at Trentuno Skin Studio, from any and all reactions, burns, claims, actions, expenses, damages, injuries, liabilities, including reasonable attorneys fees which might be asserted against them as a result of my having this procedure performed, or my purchase of products.
Clear
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