New Client Intake & Consent Form

New Client Intake & Consent Form
Name
Appointment date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ZIP code
City
Phone
Occupation
Birthdate

MonthDayYear
Date
Do you wish to receive email updates?

YESNO
Email Address
example@example.com
Do you wish to receive appointment reminders by text message?

YESNO
What are your main skin care concerns?
If you had a magic wand, how would your skin look in one month?
Any special requests today? (extractions, skin soothing, hydration, relaxation, waxing)
What products are you currently using? (Don't leave any out. All products including cleanser and sunscreen, etc.)
Please list all medications and natural supplements:
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?

YES, give me the scoop on how to look and feel beautifulNO, just here to relax
Are you currently pregnant or lactating?

YESNO
Do you have a pacemaker?

YESNO
Do you have epilepsy or other seizure disorders?

YESNO
Have you ever had Botox or Fillers?

YESNO
Have you ever been prescribed Retin A?

YESNO
Have you ever been prescribed Accutane?

YESNO
Do you have active acne?

YESNO
Are you currently using birth control?

YESNO
Any past surgeries?

YESNO
Do you smoke?

YESNO
Allergies to anything? If yes, to what?
In a scale of 1 to 5, what is your stress level?
Have you ever been prescribed antibiotics for your skin?

YESNO
Do you have active cancer or undergoing cancer treatment?

YESNO
What do you like about your skin?
Anything else you want to share? I love learning about my clients as it helps me provide superior customer service.
If you were receiving facial treatments, what is or was your favorite part of the treatment?
Who should I thank for your referral?
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.
Clients Signature*

Clear
Date*

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