Client Intake and Consent Form

Today's Date

Date

Name*

First NameLast Name

Date of Birth*

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 Wildflower Estética?*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Any recent surgery, including plastic surgery?*

YesNo

If yes, please explain:

Any known allergies (check all that apply)?

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)?

Have you ever experienced claustrophobia?

YesNo

What is your current stress level?

HighMediumLow

Are you pregnant or breastfeeding?

YesNo

Are you taking birth control or hormone replacement?

YesNo

Have you had a facial treatment before?

YesNo

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

Date

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

Have you received any of these skin care treatments?

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, which products or brands?

Have you had Botox or other injectables?

YesNo

If yes, date of last treatment?

Date

Do you have frequent breakouts?

YesNo

Do you use sunscreen?*

AlwaysOftenSometimesNever

What are your specific concerns at this time regarding your skin?

What is your skin care goal?

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 esthetician 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 (SPF30), 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 esthetician of all medical
conditions and medications I am taking, and to let the esthetician 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 esthetician of any discomfort I may feel during the session so she may adjust accordingly.

I understand that I or the esthetician 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 Wildflower Estética from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature*

Medical History

Skin