Client Skincare Intake and Consent Form

Today's Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Occupation*

How did you hear about Goddess Esthetics?*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

Have you seen a Dermatologist in the past year?*

YesNo

If yes, list the Dermatologist's name, contact info and reason for visit:

Are you currently under the care of a physician or skin care therapist?*

YesNo

If yes, provide name and contact number.

Any recent surgery, including plastic surgery?*

YesNo

If yes, please explain:

Do you have or have ever had any of the following?*

If other, please explain:

Any known allergies (check all that apply)?*

Please list any other allergies or sensitivities:

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*

Do you (check all that apply)?*

Do you suffer from sinus problems?*

YesNo

Have you ever experienced claustrophobia?*

YesNo

What is your current stress level?*

HighMediumLow

Are you pregnant or breastfeeding?

YesNo

Are you taking birth control or hormone replacement?

YesNo

Have you had a facial treatment before?*

YesNo

If yes, when was your last facial or skin treatment?

Date

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:

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 months

Have you ever had an adverse reaction after using any skin care product?*

YesNo

If yes, please check all that apply:

If yes, which products or brands?

Have you had Botox or other injectables?*

YesNo

If yes, date of last treatment?

Date

What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*

YesNo

Do you have frequent breakouts?*

YesNo

What skin care products do you currently use?*

What is your daily skin care regimen? *

Do you use sunscreen?*

AlwaysOftenSometimesNever

What are your specific concerns at this time regarding your skin?*

What is your skin care goal?*

Indicate what services or areas for which you are interested in (check all that apply):

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 Goddess Esthetics 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.

Signature*

Medical History

Female Clients Only:

Your Skin