Esthetics Consent Form

Esthetics Intake Form
Personal Information
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Emergency Contact Number*
Format: (000) 000-0000.
Name of Emergency Contact
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
DOB

MonthDayYear
Date
Occupation
How did you hear about us?
Conditions you are currently experiencing today (Please select all that apply):

HeadacheInflammationMuscle CrampsAnxietyFatigueInsomniaStressForgetfulnessOther
Are there any aroma(s) you find unpleasant? (Please select all that apply)

LavenderCitrusGeraniumPeppermintLemongrassPatchouliEucalyptusFrankincenseOther
Esthetics Information
What type of skin do you have?

NormalOilyDryCombination
What areas of concern do you have regarding your skin?

Breakouts / AcneBlackheads / WhiteheadsUneven Skin ToneSun DamageExcessive Oil / ShineWrinkles / Fine LinesDull / Dry SkinRosaceaBroken CapillariesRedness / RuddinessDehydratedSun / Liver/ Brown SpotsOther
Have you seen a dermatologist within the past year?

YesNo
If yes, please explain:
Have you ever had an allergic reaction to any of the following?

CosmeticsMedicineFoodLatexAnimalsSunscreensDrugsIodinePollenAHAsFragranceShellfishOther
Do you currently or have you used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products in the last 3 months?

YesNo
If yes, please describe:
Have you received Botox, Restylane, or Collagen injections in the last 6 months?

YesNo
If yes, please specify:
Are you sensitive to flashing or bright lights?

YesNo
Do you have a seizure disorder?

YesNo
Is there anything else you would like us to know about you before your visit?
By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that. I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
Client Signature*
Date

MonthDayYear
Date
Should be Empty:

Esthetics Intake Form

Personal Information

Esthetics Information