Esthetics Client Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

Have you ever had professional esthetic services?*

YesNo

Medical History (Select ALL that apply, past or present)

Please describe any medical conditions or previous surgeries (including cosmetic procedures like BOTOX or injectable fillers) below. (Type N/A if you have no medical conditions or surgical history)*

Type N/A if no conditions selected

Please list any over-the-counter supplements, topical skin treatments, prescription medications, and non-prescription medications you are currently taking and what they are used for. (Type N/A if not applicable)*

Are you pregnant or breastfeeding?*

Yes, I'm pregnant.Yes, I'm breastfeedingNo/Not Applicable

Are you currently wearing contact lenses?*

YesNo

Do you have any allergies?*

YesNo

If you have allergies, please list them here:

Are you currently wearing dentures?*

YesNo

Are you currently wearing hearing aids?*

YesNo

Are you currently under a physician's care?*

YesNo

If yes, please explain:

Physician's Name*

First NameLast Name

Physician's Phone Number*

Please enter a valid phone number.

Emergency Contact*

First NameLast Name

Emergency Contact's Phone Number*

Please enter a valid phone number.

Waiver

I, {name}, have completed this form to the best of my knowledge.

Consent for Treatment

I voluntarily consent to receive esthetic services, including but not limited to facials, skin treatments, and other related procedures provided by Elizabeth Rivera and MyoQi Athletics LLC. I understand that results may vary based on individual skin types and conditions.

Understanding of Services

I understand that esthetic services are designed to enhance skin health and appearance and are not a substitute for medical care by a physician.

I understand that esthetic services are provided for the purposes of improving skin condition, appearance, and health.

If I experience pain, discomfort, or adverse reactions during or after the session, I will immediately inform my esthetician so that appropriate measures can be taken. I will not hold my esthetician responsible for any pain, discomfort, or adverse reactions that I experience during or after the session.

I understand that my esthetician is not qualified to diagnose, prescribe, or treat physical/mental illness.

I affirm that I have notified my esthetician of all known medical conditions and injuries.

I agree to inform the esthetician of any changes in my health, medical, and skin condition and that there shall be no liability on the esthetician's part should I forget to do so.

Consent for Photography/Social Media Release

I consent to the taking of photographs or videos during my sessions for the purpose of documentation, treatment planning, and promotion. I understand that these images may be used for social media, marketing, and educational purposes. I acknowledge that I will not receive any compensation for the use of these images. If I do not consent to photography or social media usage, I will inform my esthetician prior to the start of my session.

Privacy Policy

I hereby consent to MyoQi Athletics LLC possessing and utilizing my medical and personal information for the purpose of providing esthetic services. All information provided will be kept confidential and will not be disclosed to third parties without my written consent, except as required by law.

By signing this release, I waive and release Elizabeth Rivera and MyoQi Athletics LLC, along with their representatives, from any and all claims and liability, past, present, and future, relating to esthetic services.

Signature*