• New Client Intake & Consent Form

    Please complete all fields honestly and thoroughly. This information helps ensure your safety and the best possible treatment outcomes.
  • Are you booking for someone under 18?*
  • Date of Birth*
     . .
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about Emma Skin Studio?*

  • Medical History

  • Any known allergies?*
  • Have you experienced any of these health conditions in the past or present?*
  • Are you pregnant or nursing?*
  • Are you prone to cold sores or fever blisters?*
  • Have you had any recent surgeries or cosmetic procedures? (botox, filler, etc.)*
  • Have you received any of these hair removal services in the last 30 days?*
  • Are you taking any blood thinners?*
  • Have you ever used or been prescribed any acne-related medications (topical or oral), including birth control or hormone-related treatments?*
  • Have you ever experienced claustrophobia?*

  • Lifestyle

  •
  • How would you describe your overall eating habits?*
  • How much water do you drink in a typical day?*
  • Do you tan or use tanning beds?*
  • Do you smoke?*

  • Male Clients

  • What is your current shaving system?
  • Do you experience irritation from shaving?*

  • Your Skin

  • Skin Type:
  • Skin Concerns:*
  • Are you currently using any of the following?
  • What skin care products are you currently use?*

  • For each product you’ve checked, please list the brand and product name you currently use. This helps us personalize your recommendations, even if you are not focused on corrective care. You may also take a photo of all your current products and either bring it to your appointment or email it to us in advance.

  • Treatment

    Now for the fun part!
  • Have you had a facial before?*

  • By signing below, I acknowledge and agree to the following:

    Health Disclosure:
    I have disclosed all medical conditions, allergies, medications, and recent treatments honestly and completely. I understand that certain health conditions, medications, or skincare products may affect how my skin reacts to treatment.

    Treatment Acknowledgment:
    I understand that skincare services are non-medical, cosmetic treatments. Possible side effects include temporary redness, irritation, dryness, or minor breakouts. Results vary from person to person, and no specific outcome is guaranteed.

    Liability Release:
    I release Emma Skin Studio and my esthetician from any responsibility for unanticipated reactions that may occur as a result of disclosed or undisclosed information.

    Cancellation / Rescheduling Policy:
    A minimum of 48 hours’ notice is required to cancel or reschedule any appointment.

    • Cancellations or changes made under 48 hours may result in a 50% charge of the scheduled service.
    • No-shows may be charged 100% of the service total and may require a deposit for future bookings.
    • Repeated last-minute cancellations may result in loss of booking privileges.

    Late Arrivals:
    If you arrive more than 10 minutes late, your appointment time may be shortened or rescheduled, and a late fee may apply.

    Deposits:
    Deposits are non-refundable but may be transferred once if rescheduling occurs within policy limits.

    Privacy:
    All personal and medical information is kept confidential and used solely for treatment and client record purposes.

    By signing below, I confirm that I have read and understood the above information and consent to receive treatment at Emma's Skin Studio.

  • Photography Consent:
  • Date
     - -

  • Thank you for taking the time to fill out your intake form! 

  • Should be Empty: