Consent and Intake Form

Consent and Intake Form

Glamour Esthetics
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Medical History
Are you presently taking any medications?
Please list.
Are you currently pregnant?
Do you have any allergies to cosmetics, food or drug?
Please specify
Do you use acne medication?
Please list.
Is there anything else, medically, that you believe your esthetician should know before the appointment?
If not, put ‘No’ or ‘N/A.’
Agreement
By signing this consent form, I have read and acknowledge that:
- If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
- I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
- I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the esthetician's part should I fail to do so.
- I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
- I acknowledge that every service that is completed at Glamour Esthetics is 100% my choice and that my esthetician did not and will never perform any service(s) or technique(s) that I did not consent to.
Also I understand that;
- The services offered are not substitute for medical care, and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in future.
- I cannot threaten or pursue legal action against my Esthetcian if I fail to meet any of the standards listed above.
Client Signature
Date

MonthDayYear
Date
Should be Empty:

Consent and Intake Form

Medical History

Agreement