• Client Intake And Consent Form

    Loved By Salem
  • Todays Date
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  • Date of birth
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  • Format: (000) 000-0000.
  • How Did You Hear About Loved By Salem?
  • What Service Are You Here For?

  • Please take a moment to answer the following questions

  • Are you presently taking any medications?
  • Are You Currently Seeing a Dermatologist?
  • Have You Had Injectables (Filler/Botox) Or Any Surgery including Plastic Surgery?
  • Are you pregnant?
  • Do you have any allergies to cosmetics, food or drug?
  • What skin care products do you currently use?
  • Have You Received A Chemical Peel, Laser Treatments (Including Hair Removal), Or Waxing?
  • Do you have Any Reactions To Skin Care Products?
  • Do you use acne medication?
  • Are you taking oral contraceptives?
  • Please check if you are affected by or have any of the following
  • Do You (Check All That Apply)

  • I agree with

    • If I experience any pain or discomfort during the session, I will immediately inform Loved By Salem so that the products and/or technique may be adjusted to my level of comfort.
    • I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
    • I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
    • I agree to keep Loved By Salem updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.
    • I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

    Also I understand that;

    • Waxing
      I understand waxing may cause redness, irritation, ingrown hairs, or skin lifting. I confirm I have not used retinoids, Accutane, or exfoliants that could thin my skin within the past 7 days. I release Loved By Salem and my esthetician from liability for reactions.
    • Lash Lift
      I understand results may vary based on my natural lashes. Risks include irritation, redness, or allergic reaction. I confirm I have not had recent eye surgery or conditions that may affect the safety of the service.
    • Brow Lamination
      I understand brow lamination involves chemical processing and may cause dryness, irritation, or uneven results. Aftercare must be followed to maintain results. I release Loved By Salem from liability for adverse reactions.
    • Lash & Brow Tinting
      I understand that tinting uses dyes and may cause allergic reaction or irritation. A patch test is recommended. I release Loved By Salem from liability for any reactions.
    • The services offered are not substitute for medical care, and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in future                                                     
    • I acknowledge that facials and skin treatments may have risks including redness, irritation, or breakouts.           
    • I have disclosed my full medical history. I release Loved By Salem from liability related to the treatment.
  • Date
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