Esthetics Client Intake
The following information is needed to help us provide the best and most comfortable experience for our clients. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Basic Info
Name
*
First Name
Last Name
Birthdate
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What do you love about your skin/complexion currently?
What do you currently dislike or have challenges with when it comes to your skin/complexion?
How many steps are in your current skin care routine?
Are you satisfied with your current skin care routine?
Yes
No
List any known allergies
*
List any prescription skin products you've used in the last 3 months.
Have you taken isotretinoin (Accutane) within the last 12 months?
*
Yes
No
Are you currently using any products that contain the following:
*
Glycolic Acid
Lactic Acid
Other Acid ingredient
Exfoliating Scrub
Vitamin A
Other Acid ingredient
None of the above
Are you currently pregnant or lactating?
*
Yes
No
Do you have of the following conditions?
*
High blood pressure
Heart problems
Headache/Migraines
Diabetes
None of the above
What is your current form of contraceptive
*
Hormonal Pill
Hormonal Injection (Depo)
IUD
Implant
Other
None
Do you have difficulty lying on your front, back, or side?
*
Yes
No
If yes, please explain
Have you experienced any of these health conditions in the past or present
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HIV/AIDS
Herpes
Frequent cold sores
None
Waxing
Have you ever had a profession wax service?
Yes
No
If yes, how many wax services have you received in the last 12 months
If yes, what type of wax services have you received
Have you ever experienced any of the following after a waxing service
Vajacial
Have you received a Vajacial before?
Yes
No
Have you ________ the area around your vagina in the last 10 days?
Waxed
Sugared
Lasered
Shaved
None of the above
Do you use any of the following products in or around your genital area?
Exfoliating products/glove
Soap
Vaginal Wash
Serums
Lotions, creams, body butters or other moisturizers
I understand that vajacial treatment may have positive or negative side effects as a result of doing a vajacial treatment. I accept legal responsibility for my choice to do a vajacial treatment and waive the responsibility of the practitioner and the facility where the vajacial treatment takes place in the case that any of the named side effects (or others) may occur. (Irritation, rash, or inflammation).
Spray Tanning
Have you received a spray tan before
Yes
No
If yes, how many?
Have you completed the following pre-tan prep
Exfoliated 2-3 days before, followed by moisturizer
Shaved (at least 6 hours prior) or Waxed (at least 24 hours prior)
Nails (no sooner than the day prior to your spray tan)
Lashes (at least 24 hours prior to your spray tan)
Facials and other spa treatments (at least 24 hours prior to your spray tan)
Shower at least an hour prior to appointment to ensure no products are on the body including deodorant, makeup, perfume, lotion, and essential oils
Hair is completely dry at time of appointment
Informed Consent and Waiver
Please review each statement and check the corresponding box
I understand/acknowledge
*
estheticians are not medical doctors or specialist such as dermatologist and do not diagnose illness, disease or physical disorder.
esthetician services are not substitutes for medical treatment.
that services offered today and in the future are not substitute for medical care and any information provided to me is purely for educational purposes and isn't diagnostically prescriptive.
that it is my responsibility to share any concerns or questions about the services I'm receiving prior to receiving them or as they come up during services.
I do not have injuries/conditions that would prevent me from recieving esthetician services.
I have not been told by a medical professional to not recieve esthetician services.
an esthetician reserves the right to end a service in case of sexual innuendo or advances from a client and that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of services and I will be liable for full payment of the scheduled service.
any information exchanged during services is confidential and only used to provide me with the best services available. I understand that an esthetician may ask questions about my health and physical conditions and I am obligated to be honest about my health history and give complete detail.
if I experience any pain or discomfort during services, I must inform the esthetician at the time it occurs
the esthetician reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate a health risk to me to the esthetician
I am responsible for being on time for my appointment and that the estitician in not obligated to extend the end time of my service due to my tardiness.
I am responsible for the time I have booked. If I miss an appointment or fail to give 24 hours notice when I need to change or cancel, I agree to pay in full for the booked appointment time.
I have stated all my medical conditions on the Client Intake Form. I have consulted a medical doctor or licensed medical healthcare practitioner regarding any checked or prescribed conditions.
that it is my responsibility to report any changes in my physical health to my esthetician. I further understand that KM5 shall not be liable for any purpose or reason should I fail to report the needed information as per this paragraph.
I have reviewed this form in its entirety and discussed all of my treatment concerns with my esthetician.
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Date
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Submit
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