Client Skincare Intake and Consent Form
  • Today's Date*
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  • Date of Birth*
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  • Medical History

  • Are you currently under the care of a physician or skin care therapist?*
  • If yes, do they advise you to RECEIVE a facial*
  • Do you have or have ever had any of the following?*

  • Any known allergies (check all that apply)?*
  • Do you (check all that apply)?*
  • Do you suffer from sinus problems?*
  • Have you ever experienced claustrophobia?*

  • Female Clients Only:

  • Are you pregnant or breastfeeding?
  • Are you taking birth control or hormone replacement?

  • Your Skin

  • Have you had a facial treatment before?*
  • If yes, when was your last facial or skin treatment?
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  • Are you currently using any products that contain or are you taking any of the following?*
  • Have you received any of these skin care treatments?*

  • If you checked any of the above, please select one:
  • Have you ever had an adverse reaction after using any skin care product?*
  • If yes, please check all that apply:
  • Have you had Botox or other injectables?*
  • If yes, date of last treatment?
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  • What do you consider your skin type?*
  • Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*
  • Do you have frequent breakouts?*
  • What skin care products do you currently use?*

  • Do you use sunscreen?*

  • By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following:

    I give my permission to receive facials, skin care treatments, eyelash and eyebrow services or waxing services.

    I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications.

    I have clearance from my physician to receive facials, skin treatments and waxing services.

    I understand the risks associated with facials and waxing include, but are not limited to:
    • Superficial bruising or redness
    • Short-term muscle soreness
    • Exacerbation of undiscovered injury

    I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. 

    I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

    I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.

    I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.

    I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.

    I understand the importance of informing my esthetician of all medical
    conditions and medications I am taking, and to let the esthetician know
    about any changes to these. I understand that there may be additional risks
    based on my physical condition.

    I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjust
    accordingly.

    I understand that I or the esthetician may terminate the session at any
    time.

    I have been given a chance to ask questions about the session
    and my questions have been answered.

    I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

    I, therefore, release Flawless Fix and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

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