Client Intake/Consent Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Medical / History Data
Are you pregnant, breastfeeding, or nursing?
*
Yes
No
Are you currently taking any prescribed medications (such as antibiotics, blood thinners, acne medications/anything from a dermatologist, etc)? If yes, please list them below:
*
Do you have any known allergies/skin sensitivities? Please list:
*
Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any Vitamin A derivatives?
*
Yes
No
If so, how recent/ how often?
Have you recently received Botox/ Dermal Fillers?
*
Yes
No
Have you recently received a chemical peel or laser treatment?
*
No
Yes- in the last month
Yes-in the last 2-3 months
Yes- more than 3 months ago
Did you undergo any major surgery in the past 90 days? If yes, please describe:
*
Medical History: Please mark any on the following conditions you may currently have
*
Autoimmune Disorder
Cold Sores or Fever Blister
Cancer
Diabetes
Dermatitis
Eczema
Epilepsy
Herpes Simplex
HIV/AIDS
Hepatitis B or C
Skin Infections
Warts
None of the Above
Other
What are your main skin concerns (select all that apply)?
*
Acne/Breakouts
Blackheads
Fine Lines and Wrinkles
Hyperpigmentation/Dark Spots
Dry/Dehydrated Skin
Oily Skin
Ingrown Hairs/Razor Burn
Age Spots
Sun Damage
Rosacea
Eczema
Dark Under Eye Circlea
Other
What is your Skin Type?
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Normal
Dry
Oily
Combination
Sensitive
What does your current skincare routine include(name and type of products used daily/weekly/monthly)?
*
Have you ever experienced Claustrophobia?
*
Yes
No
Authorization
By submitting and signing this form, I acknowledge, and consent to the following:
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments.
I acknowledge that the esthetician holds the right to terminate the session at any time.
I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received.
I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.
I release the esthetician from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.
Date
*
-
Month
-
Day
Year
Date
Signature
*
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