New Client Intake Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date

How did you hear about LA?

List any medications/ supplements/ remedies you are currently taking:

Please share all allergies/ sensitivities:

Please upload a photo without makeup of treatment area in natural lighting:

What are your specific concerns regarding your skin at this time:

What is your current stress level

Have you received professional cosmetic/ skin rejuvenation treatments before?

What do you consider your skin type?

What products do you use daily on your skin? (list brands if possible)

What are your treatment goals?

Please check all that apply:

Signature

At LA, we specialize in enhancing your natural beauty with a blend of modern technology and timeless techniques. Our services include eyelash enhancments, eyebrow reconstruction, professional permanent makeup, laser, medical grade facials, hair restoration, body contouring, a wide range of skincare treatments and advanced therapies including wellness shots, Morpheus8, Forma, Diolaze XL, Lumecca, SkinPen systems, and regenerative treatments like Exosomes, stem cell therapy, VAMP, and NCTF.

I agree to the following terms and conditions:

By submitting this form, I acknowledge and agree to the following terms:

I consent to receive professional facial treatments and personalized skincare recommendations from a licensed esthetician.
I understand that while every effort will be made to achieve optimal results, outcomes may vary and are not guaranteed.
I acknowledge that my esthetician is not a medical doctor and, therefore, does not diagnose medical conditions, offer medical treatment, or prescribe medications.
I confirm that I have received medical clearance from my physician, if necessary, to proceed with facial and skincare treatments.
I am aware of the potential risks and side effects associated with skincare and facial treatments, and I voluntarily assume all such risks. I hereby release LA & staff from any liability for complications that may arise during or following treatment.
I understand the importance of disclosing all current medical conditions, medications, allergies, and recent procedures, and agree to update my esthetician on any changes to my health status.
I recognize that my comfort and safety are a priority and agree to communicate any discomfort during the session so appropriate adjustments can be made.
I understand that either I or the esthetician reserves the right to discontinue the session at any time, for any reason deemed appropriate.
I confirm that I have had the opportunity to ask questions regarding the nature and purpose of the treatment(s), and that all of my questions have been answered to my satisfaction.
I acknowledge that achieving desired skincare results is a collaborative effort between myself and my skincare professional and may require consistency and ongoing care.