Form
Existing Client Contact
This form is for existing clients. There is an initial intake form which you have already submitted for all first-time clients. If any part of your lifestyle, medication, health history has changed or should be updated since the initial intake, or even if some medications you previously listed have been discontinued this is the place to document it.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Questions
Please answer completely and honestly
Are you taking any prescription topical creams or eye creams with retinoids like Differin, Acuutane, or Tretinoin? If so, how often do you use it and when was the last time you used it?
Have you waxed or used any depilatory products like Nair in the last 7 days? If so, please list how many days ago and which part of the face (or treatment area).
Do you use any chemical exfoliators or skin brighteners? AHA/BHA products? How often do you use these products? (ie. Mandelic Acid, Glycolic Acid, Salicylic Acid, Lactic Acid, Kojic Acid, Arbutin)
Are you seeing a physician for any current condition?
Are you pregnant or trying to become pregnant?
Please use this field to list any new information about your daily regimen, supplements, medications, and sensitivities that I should be aware of for this appointment.
Type a question
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 (SPF35), 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 not 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
I release Velvet Esthetics LLC and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Signature
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