• New Client Intake & Consent Form

    New Client Intake & Consent Form

  • Appointment date
     / /
  • Format: (000) 000-0000.
  • Birthdate
     / /
  • Do you wish to receive email updates?
  • Do you wish to receive appointment reminders by text message?
  • Knowing that home care is a big part of achieving beautiful skin, would you like to chat about how to maintain today's results at the end of the facial?
  • Are you currently pregnant or lactating?
  • Do you have a pacemaker?
  • Do you have epilepsy or other seizure disorders?
  • Have you ever had Botox or Fillers?
  • Have you ever been prescribed Retin A?
  • Have you ever been prescribed Accutane?
  • Do you have active acne?
  • Are you currently using birth control?
  • Any past surgeries?
  • Do you smoke?
  • Have you ever been prescribed antibiotics for your skin?
  • Do you have active cancer or undergoing cancer treatment?
  • Please read carefully and initial the following:

  • * I understand that Silky Skin services including facials and body treatments given at Silky Skin, are for the sole purpose of skin cleansing, body and mind relaxation and rejuvenation.

  • * I understand that it is imperative to tel my Esthetician about any oral or topical medications prior to any facial, waxing, or body treatment services.

  • * I understand that Silky Skin does not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of Silky Skin at my own risk, and to not hold Silky Skin liable for loss, damage or injury.

  • * I understand that there are no specific guarantees of the results can or have been made and that there is the possibility I may required additional treatments/procedures to obtain the expected results at an additional cost.

  • * I consent to “before-and-after" photographs for the purpose of documentation, potential advertising, and potential promotional purposes.

  • * I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible, and will hold her harmless from any liability that may result from this treatment. I do not hold the Esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I agree that this constitutes full disclosure, and that it supersedes any previous verbal and written disclosures.

  • Date*
     / /
  • 2355 Honolulu Avenue, Suite 201, Montrose, CA 91020
    818-334-4926
    silky-skin.net

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