Consultation Form
Full Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Pronouns
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Please Select
she/her
he/him
they/them
prefer not to say
Contact Number
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Format: (000) 000-0000.
Email Address
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example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did you hear about us
Instagram/Tiktok
Referral
Google
Walked In
Online Search
If Referred, by who?
First Name
Last Name
Emergency Contact Name
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First Name
Last Name
Emergency Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Relationship To Emergency Contact
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Check the conditions that apply to you
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Hormone Imbalance
High Blood Pressure
Heart problem
Auto-immune Disorder
Epliepsy/Seizures
HIV/AIDS
Depression/Anxiety
Arthritis
Cold sores
Lupus
Headaches/ Migranes
None
Other
Are you currently taking any medication?
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Yes
No
Please list them.
Do you have any allergies?
Yes
No
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
Have you received any Botox/Fillers If so when?
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-
Month
-
Day
Year
Date
Have you received any Botox/Fillers If so where?
List Any Skin Concerns
What would you say your skin type is
Normal (no visible blemishes, fine pores, smooth texture)
Combination (oily and dry patches, oily t-zone, hormonal breakouts)
Acne (cystic or nodules)
Dry (dull, visible lines and wrinkles, feels tight)
Oily (enlarged pores, excessive oil)
Sensitive (reactive to fragrance, often irritated)
Select that applies to your skin type
Hormonal Acne
Dehydrated/ Dry Skin
Congestion around T-Zone
Dry patches
Hyperpigmentation
Scarring from acne
Blackheads
Inflamed blemishes/Acne
Wrinkles
None
Other
What skin care products do you use daily/weekly
Cleanser
Bar Soap
Toner
SPF
Exfoliator products
Moisturizer
Vitamin A (Retinol)
Glycolic/ Lactic Acid
Serum
Eye Cream
Hyaluronic Acid
Salicylic Acid
None
Other
Have you been diagnosed with eczema, psoriasis or rosacea?
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Yes
No
Are you currently pregnant or breastfeeding
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Yes
No
Do you currently use any prescribed medication, topically or orally?
*
Accutane
Retin-A
Prescribed topical cream
None
Have you received any of these facial hair removal services in the last 30 days?
*
Waxing/Sugaring
Threading
Laser/ Electrolysis
Chemical Peels
At Home Dermaplane
Facial Services From Another Provider
None
Please specify what product, type & brand is used. If you are Prescribed topical cream, what is it used for?
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I Consent 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 (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.I acknowledge that this treatment is strictly 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 no part of the recommended take-home regimen for 2-4 weeks following treatment.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 release Kaleaili and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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I consent; that I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complicationsI also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.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 of 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 have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. 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.
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