Client Consent Form and Questionnaire
For a service with Abbigayle Garner. Please submit within 48 hours of service.
Client Info
Legal Name (for legal reasons only). You will not be referred to by this name unless it is preferred.
*
First Name
Last Name
Preferred Name (this is what you will be referred by).
First Name
Last Name
Pronouns
Date of Birth
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/
Month
/
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Please provide an emergency contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation
Date of Appointment
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Month
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Day
Year
Date
Type of service you are receiving (Select all that apply).
*
Lash Extensions
Lash Lift
Brow Lamination
Lash Tint
Brow Stain
Waxing
Facial
Dermaplaning
Oxygen Treatment
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Pre-Appointment Questionnaire
All medical/health questions are for your safety to limit risks and complications that may come along with select services for some individuals. This information is kept confidential between you and Abbigayle, and will not be shared outside of your appointment.
Are you experiencing any cold or flu-like symptoms?
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Yes
No
Have you been under the care of a dermatologist or other physician within the past year? If yes, please specify. If inapplicable, put 'N/A.'
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Please list ALL medical conditions/health problems you have had in the past or present. i.e. illnesses, diseases, skin conditions, infections. If inapplicable, put 'N/A.'
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Please list any prescription medications you use regularly, including any supplements, vitamins, accutane, oral contraceptives, etc. If inapplicable, put 'N/A.'
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Do you have any allergies, including any food, cosmetic, latex, or medicine allergies? Please specify, and if inapplicable put 'N/A.'
*
Are you currently pregnant and/or breastfeeding?
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Yes
No
Do you have any history of skin cancer
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Yes
No
Do you have any metal implants? i.e. pacemaker, piercings, permanent retainers, etc.
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Yes
No
Do you have any disabilities or neurodivergent/anxiety needs? I will accommodate you to the best of my ability. Select all that apply or specify below.
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Fidget or sensory tools
Stretch breaks for long services
Claustrophobia
Silent appointment
No strong scents
Specific music or sounds
Pillow for under knees, back, etc.
None
Other, please specify below
If other was selected, what can I do to make your service more comfortable for you? I will accommodate to the best of my ability.
Is there anything else you would like Abbigayle to note before your appointment? If none, put 'none.'
*
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Skincare History
Tell Abbigayle about your skin wants and needs.
Have you ever had the above checked service(s) done before?
*
Yes
No
If yes, how frequently?
Regularly
Occasionally
Rarely Ever
Have you had any of the following treatments done within the last two weeks in the area being serviced?
*
Waxing
Microdermabrasion
Chemical Peels
Dermaplaning
Injections, Surgery, etc.
None of the above
Have you used a tanning bed, or have had excessive UV exposure in the past 48 hours?
*
Yes
No
Do you smoke? (Cigarettes, Tobacco, E-Cigarettes, Vape)
Yes
No
How many oz. of water do you drink in a day?
How much caffeine do you consume in a day?
Do you use or have you used Retin-A, Renova, AHAs, Retinol or any Vitamin A derivative products in the past 3 months? If yes, please specify:
*
What is your skin type?
Please Select
Dry
Normal
Combination
Oily
I'm not sure
What type of products do you use on your skin? (i.e. cleansers, toners, spf, moisturizers, makeup, etc.)
Do you have any specific skincare concerns or challenges? What are your goals with your skin?
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Acknowledgement and Waiver
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I agree to not bring any guests, including children, without prior approval.
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I agree to my service being potentially photographed and/or recorded, and shared on Abbigayle's social media and website.
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I understand and agree that Abbigayle is not responsible for my health and wellbeing if I fail to identify and disclose my allergies to elements or ingredients that will be used for my service.
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I understand that there will be no refund if allergic reaction, discomfort, or irritation occurs.
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I understand that specific services require aftercare and if proper aftercare is not performed, results of the service may not last. This may result in damage, infection, or irritation, and Abbigayle is absolved from any responsibility.
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I agree to verbally disclose any skin conditions, allergies, illnesses, or infections before my service is started.
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I understand that Abbigayle is not a medical professional and can deny a service and/or ask for written approval from a doctor if there is a significant risk involved due to health complications, pregnancy, allergies, diseases, skin conditions, etc.
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I understand that not everyone is a good candidate for the service I am receiving, and Abbigayle holds the right to deny a service if she suspects that there may be health risks involved with moving forward, or if the area is not suitable for the service.
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I understand that if I am age 18 or under, parental or guardian consent is required before receiving the service and that a parent or guardian must be present at the beginning of the appointment to sign consent forms. I understand that Abbigayle is not responsible if the client is dishonest about their age.
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I identify and hold harmless Abbigayle Garner against any claims, expenses, damages, and liabilities.
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I have read and agree to Abbigayle's service policies below and give consent to receive the scheduled service. I understand that it is my responsibility to read the service policies provided below.
CLICK
HERE
TO VIEW ASTRO AESTHETICS SERVICE POLICIES.
Client Signature
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Date Signed
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Month
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Day
Year
Date
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