Facial Treatment Intake Form

Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
Please enter a valid email.
Phone Number*
Please enter a valid phone number.
Emergency Contact*
Full Name / Phone Number
Medical History*

AcneAutoimmune disordersCold sores or fever blistersCOPDCancerDiabetesDermatitisEczemaEpilepsyGlaucomaHeart DiseaseHigh Blood PressueHepatitis B or CHerpes simplexHemophiliaHIV/AIDSKeliods or hypertrophic scarsMigrainesPsoriasisRosaceaSkin infectionSeborrheicUrticaria (hives)WartsNoneOther
What are your main skin concerns?*

Acne / BreakoutsBlackheadsWhiteheadsSun damageAge spotsMelasmaScarsFine lines and wrinklesHyperpigmentationIngrown hairsRazor burnRosaceaEczemaEnlarged poresSkin rednesUnder-eye puffinessUneven skin toneUneven skin texturePsoriasisFacial HairOther
What is your skin type?*

NormalDryOilyCombinationSensitiveAcne-proneAgingDehydratedRosacea-proneSun-damagedHyper pigmentedPsoriasis-proneOther
What is your skin routine?*

Foam cleanserGel cleanserMakeup removerTonerMoisturizerEye creamSunscreenFace maskExfoliantSerumSpot treatmentFacial oilNoneOther
List all medications you are currently taking.*
If none, please type "N/A"
List any known allergies.*
If none, please type "N/A"
Within the last year, have you undergone any surgery or plastic surgery?*
If none, please type "N/A"
Client Consent Form

I hereby consent to and authorize my esthetician to perform the following procedure:

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.

While it is not possible to list every risk and complication, I have been made aware of the potential benefits, risks, and complications. Moreover, I understand that there are no certain outcomes and that individual results may rely on factors such as age, skin condition, and lifestyle. There is also a possibility that I may need further treatments on the treated areas to achieve the desired outcomes, at an additional expense.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, whose signature appears below, 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.

The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.

I have read the information and recorded my medical history accurately. For future services, I agree to inform my esthetician of any changes in my medical status.
I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure described above.*

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Todays Date*

MonthDayYear
Date
Cancelation Policy Form

We are committed to providing all of our clients with exceptional care in a timely manner. For this reason, we have instituted a 24 hour cancellation policy for all appointments.

We understand that sometimes life gets in the way and appointments need to be rescheduled or canceled. However, we kindly ask that you provide at least 24 hours' notice if you need to cancel or reschedule your appointment. This allows us to offer the time slot to another client who may be waiting for an appointment.

If you need to cancel or reschedule within 24 hours of your appointment, a fee of 50% of the service cost will be charged. If you do not show up for your appointment and do not provide any notice, the full cost of the service will be charged.

If you are late we reserve the right to cut your service, you will be charged for the service you booked not the cut service. If you are more than 15 minutes late and we do not have enough time to perform the service due to timing, you will be charged in full.

We appreciate your understanding and cooperation in following our cancellation policy. Our goal is to provide the best possible service to all of our clients, and this policy helps us achieve that goal by ensuring that our estheticians' time is used efficiently and effectively.
I have read this policy and understand that I need to provide at least 24 hours notice when rescheduling or cancelling an appointment. If I fail to contact the office at least 24 hours in advance, I will be charged the appropriate cancellation fee.*

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Todays Date*

MonthDayYear
Date
Photo & Video Release Form

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes: conference presentations, educational presentations or courses, informational presentations, on-line educational courses, educational videos.

By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.
By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.*

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Todays Date*

MonthDayYear
Date
Should be Empty:

Client Consent Form

Cancelation Policy Form

Photo & Video Release Form