Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Are you currently under a physicians care?*

YesNo

Please list any current medical conditions *

Are you pregnant or nursing ?*

YesNo

Are you currently taking any medications, vitamins or supplements ? *

Do you have any?*

YesNo

If yes, please list them. Please describe reactions*

Type a question*

Do you experience:*

List current skincare products you use regularly .*

Any cosmetic treatments in the last 6 as months ? *

Doo you wear SPF daily?*

YesNo

What are your main skin concerns/ goals?*

How soon are you hoping to see results?*

I understand that the treatments I receive at GREEN Haus Aesthetics and Skincare are for the purpose of improving the health and appearance of my skin. I acknowledge that while these services can produce noticeable improvements, results are not guaranteed and may vary from person to person.

I have disclosed all relevant health information, including current medications, medical conditions, allergies, and recent cosmetic procedures. I understand that withholding information may increase the risk of adverse reactions, and I release GREEN Haus Aesthetics and Skincare from any liability related to complications that may arise as a result.

I acknowledge that some treatments, including but not limited to chemical peels, microneedling, dermaplaning, extractions, and waxing, may cause temporary redness, irritation, sensitivity, or other side effects. These effects are typically temporary and part of the normal healing process.

I have had the opportunity to ask questions about my treatment, and all questions have been answered to my satisfaction. By signing below, I consent to the proposed services and agree to follow all aftercare instructions provided to me

Signature*

Date*

Date

GreenHaus Aesthetics & Skincare Client Intake Form

Medical History

Allergies

Skin History

Treatment Goals

Consent & Agreement