Client Skincare Intake and Consent Form

Facial Client Intake and Consent Form (Confidential)
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Occupation*
How did you hear about Legacy Skin + Beauty?*

Facebook/InstagramOnline SearchReferralOther
If referred, by who?
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Medical History
Have you seen a Dermatologist in the past year?*

YesNo
If yes, list the Dermatologist's name, contact info and reason for visit:
Are you currently under the care of a physician or skin care therapist?*

YesNo
If yes, provide name and contact number.
Any recent surgery, including plastic surgery?*

YesNo
If yes, please explain:
Do you have or have ever had any of the following?*

Hormone ImbalanceCancerSkin Disease/LesionsSystemic DiseaseHigh Blood PressureDiabetesArthritisAuto-Immune DisorderAsthmaEpilepsy/SeizuresFrequent Cold SoresHerpesHIV/AIDSHepatitisLupusDepresssion/AnxietyHeadaches/MigrainesSunburnEczemaHemophiliaPsoriasisHeart ProblemsPhlebitis, Blood Clots, Poor CirculationMolesThyroid ConditionNeck or Spinal InjuryAny active infectionKeloid ScarringFibromyalgiaHead or Neck PainNone of the aboveOther
If other, please explain:
Any known allergies (check all that apply)?*

AspirinLatexFruitsLidocaneFragrances/Essential OilsTree NutsDairySunscreenPollenNoneOther
Please list any other allergies or sensitivities:
List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*
Do you (check all that apply)?*

SmokeConsume alcoholUse any recreational drugsConsume caffeineConsume water regularlyExercise regularlyFollow a restricted dietHave a pacemakerHave any metal implantsWear contact lenses or glassesFrequent tanning boothsNone
Do you suffer from sinus problems?*

YesNo
Have you ever experienced claustrophobia?*

YesNo
What is your current stress level?*

HighMediumLow
Female Clients Only:
Are you pregnant or breastfeeding?

YesNo
Are you taking birth control or hormone replacement?

YesNo
Your Skin
Have you had a facial treatment before?*

YesNo
If yes, when was your last facial or skin treatment?

MonthDayYear
Date
Are you currently using any products that contain or are you taking any of the following?*

Acne MedicationPrescribed topical creamRetinol/Vitamin A derivative productsProducts containing Hydroquinone or Alpha HydroxyAHA's (Glycolic Acid, Lactic Acid, etc.)BHA (salicylic acid)None
Have you received any of these skin care treatments?*

Chemical PeelMicrodermabrasionDermaplaningMicroneedlingFacial UltrasoundLaser Hair RemovalLaser TreatmentsWaxingNoneOther
If you checked any of the above, please select one:

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 months
Have you ever had an adverse reaction after using any skin care product?*

YesNo
If yes, please check all that apply:

RashIrritationPeelingSun SensitivityBreakout
If yes, which products or brands?
Have you had Botox or other injectables?*

YesNo
If yes, date of last treatment?

MonthDayYear
Date
What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*

YesNo
Do you have frequent breakouts?*

YesNo
What skin care products do you currently use?*

SoapCleanserTonerExfoliator or ScrubMaskMoisturizerSunscreenNoneOther
What is your daily skin care regimen? *
Do you use sunscreen?*

AlwaysOftenSometimesNever
What are your specific concerns at this time regarding your skin?*
What is your skin care goal?*
Indicate what services or areas for which you are interested in (check all that apply):

Minimize/Remove Sun Spots / Brown SpotsMelasmaWrinkle ReductionAcne TreatmentMicroneedlingRosaceaGeneral Skin CareOther
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.
Signature*

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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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Facial Client Intake and Consent Form (Confidential)

Medical History

Female Clients Only:

Your Skin