CMG_skin New client intake / Consent form

CMG_skin New Client Intake and Consent Form
Personal Info
Date

MonthDayYear
Date
Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
How did you hear about CMG_skin*

Website theCMGlifestyle.comInstagramReferralOther
If Referral, please list whom*
Have you experienced any of these health conditions?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart ProblemsArthritisAuto_Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV / AIDSLupusDepression / AnxietyHepatitisHeadaches / MigrainesThyroid IssuesNoneOther
Have you had any physical injuries your practitioner should know about*

YesNo
If yes, please specify
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsSuffer from claustrophobiaNone
Any known allergies*

AsprinTree nutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsLidocaineNoneOther
Do you smoke

YesNoSocially
Are you prescribed any Hormone replacement therapy*

YesNo
If yes, please specify
Are you taking Birth Control

YesNoN/A
Are you pregnant or trying to become pregnant*

YesNoCurrently breastfeedingN/A
Are you experiencing any Menopause issues/symptoms

YesNoN/A
If yes, please specify
Have you ever had treatment to your skin or a facial*

YesNo
If yes, when and what?
What are your skincare goals?
Current skin challenges or conditions*

Fine lines / WrinklesSun damage / Hyperpigmentation / MelasmaAcne / Acne scarringRedness / RosaceaAgingDryness / FlakinessSensitivityEczemaPsoriasis
What skincare products do you currently use?*

CleanserBar soapFace scrub / ExfoliatorTonerSerumsMoisturizerSunscreenEye creamLip products
Please specify
Do you, or have you used Retin-A products, Acids or Enzymes?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoUnsure
Please specify
Received any hair removal in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepilatory CreamShavingNone
If yes, please specify when
Have you ever received?*

Chemical peelsLaser servicesMicrodermabrasionMicroneedlingHydrafacialDermaplainingLED light
If yes, please specify when and any complications
Have you received any facial injections in the past 2 weeks: Botox, Dysport, Juvaderm, other dermal fillers*

YesNo
Have you used or been prescribed any acne medication? Oral or topical.*

YesNo
Please specify*
Do you consent to photos/videos being taken for social media marketing purposes?*

YesNo
MALE Clients: What is your current shaving system?

Razor / Wet shaveElectricNone
MALE Clients: Do you experience irritation from shaving?

YesNoN/A
Post Facial Care Instructions
Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 50. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Chemical peels, Enzyme peels, Microdermabrasion or Microneedling treatments can result in skin flushing/redness or skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
Client Initials *

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Reservation & Cancellation Policy

Recognizing that everyone’s time is valuable and the appointment times are limited, we ask that you provide a 48 hour notice if you are unable to keep your appointment. When booking an appointment for your first visit to CMG skin Spa, a credit card is required and kept on file. Authenticated by a $0.01 charge. In the event of a cancellation or if a request to reschedule is received less than 48 hours prior to appointment, a cancellation fee of up to 50% of treatment cost will incur. No Shows or Same Day Cancellations will be charged 100% of the service scheduled. This fee cannot be put towards a future service. These policies are subject to change.
Client initials*

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Truthful Disclosure
I understand and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin and/or body from treatments received. The treatments I receive here are voluntary and I release CMG_skin and The CMG Lifestyle LLC from all liability and assume full responsibility thereof.
Client Initials*

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Signatures
This contract may be signed electronically or in hard copy. If signed in hard copy, it must be returned priot to the appointment to the Business for valid record. Electronic signatures count as original for all purposes.
By typing their names as signatures below, both parties agree to the terms and provisions of this agreement.
Client Signature *

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Client Name printed
Date of Client signature

MonthDayYear
Date
As your Practicioner, Licensed Esthetician and Owner of CMG_skin and theCMGlifestyle LLC, I, Christina M Greene, am responsible for keeping all medical records, information obtained here in this document and any and all personal information obtained during all procedures performed here at CMG_skin facility, private, protected and secure. Only signure approved pictures and/or video of procedures for marketing purposes (if consent was given above) will be used in any other fashion. Thank you for putting your trust and your face in my hands.

Christina M Greene
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Personal Info