Client Skincare Intake and Consent Form

  • Facial Client Intake and Consent Form (Confidential)

  • Today's Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • How did you hear about Legacy Skin + Beauty?*
  • Format: (000) 000-0000.

  • Medical History

  • Have you seen a Dermatologist in the past year?*
  • Are you currently under the care of a physician or skin care therapist?*
  • Any recent surgery, including plastic surgery?*
  • Do you have or have ever had any of the following?*
  • Any known allergies (check all that apply)?*
  • Do you (check all that apply)?*
  • Do you suffer from sinus problems?*
  • Have you ever experienced claustrophobia?*
  • What is your current stress level?*

  • Female Clients Only:

  • Are you pregnant or breastfeeding?
  • Are you taking birth control or hormone replacement?

  • Your Skin

  • Have you had a facial treatment before?*
  • If yes, when was your last facial or skin treatment?
     - -
  • Are you currently using any products that contain or are you taking any of the following?*
  • Have you received any of these skin care treatments?*
  • If you checked any of the above, please select one:
  • Have you ever had an adverse reaction after using any skin care product?*
  • If yes, please check all that apply:
  • Have you had Botox or other injectables?*
  • If yes, date of last treatment?
     - -
  • What do you consider your skin type?*
  • Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*
  • Do you have frequent breakouts?*
  • What skin care products do you currently use?*
  • Do you use sunscreen?*
  • Indicate what services or areas for which you are interested in (check all that apply):

  • By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following:

    I give my permission to receive facials, skin care treatments, eyelash and eyebrow services or waxing services.

    I understand that the aesthetician does not diagnose illnesses or injuries, or prescribe medications.

    I have clearance from my physician to receive facials, skin treatments and waxing services.

    I understand the risks associated with facials and waxing include, but are not limited to:
    • Superficial bruising or redness
    • Short-term muscle soreness
    • Exacerbation of undiscovered injury

    I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. 

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

    I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.

    I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.

    I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.

    I understand the importance of informing my aesthetician of all medical
    conditions and medications I am taking, and to let the aesthetician know
    about any changes to these. I understand that there may be additional risks
    based on my physical condition.

    I understand that it is my responsibility to inform my aesthetician of any discomfort I may feel during the session so he/she may adjust
    accordingly.

    I understand that I or the aesthetician may terminate the session at any
    time.

    I have been given a chance to ask questions about the session
    and my questions have been answered.

    I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

    I, therefore, release Legacy Skin + Beauty and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

  • Cancellation – If you have an appointment, this time is reserved exclusively for you. If you must cancel your appointment, we require a minimum of 12-hour notice in advance for services. You are required to pay an additional $50 fee upon canceling your appointment before rescheduling. 


    No Call/No Show - if you miss your appointment without prior notification, you will be charged the 50% of the missed procedure for this scheduled appointments. I’m very considerate of your time; please do the same for me. Multiple offenses will result in you no longer being a client of Legacy Skin + Beauty.


    Late Arrival – Please note that if you are 15 minutes late for your appointment we may have to reschdule your service. If we do not hear from you 15 or more minutes into your scheduled appointment time it is considered a "no-show" and will be treated as a missed appointment. It will be up to the practitioner's discretion to allow the services to continue or reschedule you for a future appointment. Upon rescheduling, you will be charged the rescheduling fee of $50.


    Scheduling Appointment - A deposit is required to book services. This deposit varies depending on the service that you have booked. This deposit will be deducted from your appointment total. I so look forward to seeing you! 


    Children Under 18 – Parents must sign consent forms. Please bring parent to your first appointment to go over risks, forms and expectations. This is vital to be able to keep your appointment! 


    Cell Phones –Cell phone use is not permitted while permanent makeup services are rendered. 


    All purchases and services are final, and there are NO refunds. 


    Additional Treatment Policy - 


    1. We reserve the right to refuse services to anyone. 
    A. Undisclosed skin conditions (including sunburn/suntan)
    B. Under the influence of drugs or alcohol
    C. Any behavior, which is the practitioner's opinion, might compromise the artist’s or
    D. Studio’s ability to work safely and comfortably toward the desired results or disrupt other clients. 

    2. Only clients receiving service will be allowed within the treatment room.

    3. Your deposit is due upon scheduling is non-refundable. 

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