• New Client Intake Form

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -

  • Please take a moment to answer the following questions about your skin:

  • What are your skin cocerns ?*
  • Have you received chemical peels, laser services or Microdermabrasion treatment?*
  • What skin care products do you currently use?*

  • Please take a moment to answer the following questions about your health conditions:

  • Are you presently taking any medications?*
  • Please list*
  • Are you pregnant?*
  • Do you have any allergies to cosmetics, food or drug?*
  • Are you allergic to any of the following?*
  • Have you had skin cancer?*
  • Do you use acne medication?*
  • Are you taking oral contraceptives?*
  • Please check if you are affected by or have any of the following*

  • I agree with

    • If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
    • I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
    • I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such.
    • I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the esthetician's part should I fail to do so.

    Also, I understand that;

    • The services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in the future
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: