New Skin Client Intake Form

New Client Intake, Consent and Waiver Form
Lunar Esthetix is located:

609 East Main St, Suite 3, Endicott, NY, 13760
About You
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Format: (000) 000-0000.
Email:*
Address:*

Street Address

Street Address Line 2

City State

Zip Code
Preferred Method of Contact:*
How did you hear about Lunar Esthetix?*
Service Preferences

This section helps me craft the most relaxing and comfortable experience for you.
What type of treatment would you like?*
Music preference during your treatment:*
Do you give permission to photograph/video before, during, and/or after treatment for marketing purposes such as Reels or Before+After photos on TikTok, Instagram and Facebook?*
Jelly masks make great add-ons for anyone receiving a facial treatment such as dermaplane, chemical peels, hydrodermabrasion/microdermabrasion, extractions or facial waxing or in general as they aide in calming and soothing the skin, reducing redness and irritation, they seal in moisture and hydration and are extremely cooling. Would you like to add one on to your treatment today for an additional $10.00?*

Yes, pleaseNo, thank you
This treatment uses brilliant eye technology that replenishes cholesterol to enhance lipid levels and barrier function while heat and gentle vibration stimulate blood circulation and lymphatic drainage, boosts absorption, and improves the skin. Together this treatment helps soothe, de-puff, brighten, plump and awaken the eyes and the surrounding skin. Would you like to add on to your treatment today for an additional $20.00?*

Yes, pleaseNo, thank you
Medical History
Do you have or have you ever experienced any of the following?*
Are you currently pregnant, trying to become pregnant or breastfeeding?*
Have you had any recent surgeries (cosmetic or medical) or injectable's (Botox, fillers, etc) in the treatment area?*
If yes, about how long ago?
Do you have any back or spinal conditions? If yes, what?*
Please list all prescriptions and over-the-counter medications, vitamins and supplements you take:*
Have you used Tretinoin or Accutane?*
If you have used Tretinoin within the last 7–14 days or if you have used Accutane within the last 12 months and are scheduled for a facial, your appointment will need to be rescheduled. This policy is in place for the safety of your skin, as these medications can cause severe sensitivity and reactions when combined with facial services.
In the last 7 days, have you used:*
Do you have any known or suspected allergies to the following:*
Allergy trigger method?*
Your Treatment
Have you had a professional skin treatment before? If yes, when?*
What did you like and not like about your previous experience?*
Any history of skin cancer or suspicious lesions?*
How would you describe your skin?*
What are your skin concerns?*
If comfortable, please upload a picture of any skin concerns with no makeup or filters.
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What lip treatment would you like?*
What would you prefer while enzymes/masks sit (please select two)*
What does your current skincare routine look like?*
Is there anything you think I should know that was not covered before we begin?*
Consent, Liability and Policy Waiver

Please read the waiver before signing
- Client Consent, Liability Waiver, and Policy Acknowledgment
  Lunar Esthetix LLC
  
  This legally binding agreement is entered into by the undersigned client (hereinafter referred to as “Client”) and Shakiyla Trevett, also known as Shay Trevett, owner of Lunar Esthetix LLC (hereinafter referred to as “Service Provider”).
  
  ⸻
  
  1. Scope of Services & Treatment Types
  
  I acknowledge that this waiver applies to all services performed by Lunar Esthetix LLC, including but not limited to:
      •    Facial treatments (including general skin analysis, dermaplane, HydroJelly masks, eye treatments, lip treatments, chemical peels, LED light therapy, high frequency, Gua Sha comb, facial massage, microcurrent wand, peptide masks, hydrodermabrasion, microdermabrasion, oxygen treatments, facials completed with Circadia, Hale & Hush, Aqualina, Esthemax and SkinScript skincare products.)
      •    Scalp treatments (including scalp massage using Golden Jojoba Oil, electric scalp massagers, brushes, Gua Sha combs, LED light therapy and high frequency)
      •    Back treatments (including exfoliation, targeted skincare and masks using Circadia, Hale & Hush, Aqualina, Esthemax and SkinScript skincare products, hydrodermabrasion, microdermabrasion and massage)
  
  • Brow chemical services (brow color enhancement, brow tinting, brow coloring, brow dyeing, brow lamination and brow services using Thuya Professionals, Satin Smooth, Brow Code, Paris Lash Academy, Gigi and Brow Daddy products)
      •    Facial waxing services (including brows, upper lip, chin, underarm waxes and post wax skincare treatment)
  
  I understand these services are offered to individuals of varying ages, including preteens (with parental consent), teenagers, and adults. I confirm I am either of legal age or have proper parental/legal guardian authorization to receive services.
  
  ⸻
  
  2. Medical Status, Pregnancy & Oncology Care
  
  I confirm that I have disclosed all current and prior medical or health conditions including, but not limited to:
      •    Chronic or autoimmune conditions
      •    Pregnancy or nursing
      •    Recent surgeries or active infections
      •    Known allergies, medications, or sensitivities
      •    Ongoing oncology care or history of cancer treatment
  
  I acknowledge that the Service Provider is not a licensed medical professional and therefore cannot diagnose, treat, or medically clear me for services. I understand all recommendations are made using best professional judgment and based solely on the information I have provided. I release Lunar Esthetix LLC and Shakiyla Trevett from any liability associated with adverse effects, complications, or injuries resulting from undisclosed or misrepresented health conditions.
  
  ⸻
  
  3. Consent to Treatment & Professional Limitations
  
  I voluntarily consent to receive the treatment(s) scheduled and understand that all services are cosmetic and non-medical in nature. I have had the opportunity to discuss the nature, purpose, expected benefits, and risks of the treatment with the Service Provider. I understand that results are not guaranteed and that each client responds differently depending on age, skin type, medical history, and lifestyle factors.
  
  I acknowledge that while treatments are recommended with professional care and discretion, the Service Provider cannot guarantee their suitability or safety for every individual, particularly in the absence of full medical clearance. I assume full responsibility for proceeding with treatment after being informed of potential risks and limitations.
  
  ⸻
  
  4. Annual & Per-Session Consent Requirement
  
  I agree to complete a full client intake and consent form annually and a shorter, updated consent form at each appointment to confirm any changes in health status, medication use, or skincare routines. I understand that this is required for my safety and that failure to provide updated information may increase my risk of complications.
  
  ⸻
  
  5. Post-Treatment Care & Client Responsibility
  
  I acknowledge I have received or will be provided with post-treatment care instructions. I understand that improper aftercare may result in diminished results or adverse effects, and I assume full responsibility for any outcome resulting from failure to follow instructions. I agree to contact the Service Provider promptly with any questions or concerns following treatment.
  
  ⸻
  
  6. Scheduling, Cancellation & Payment Policies
  
  I understand and agree to the following policies:
      •    Cancellations or reschedules must be made at least 48 hours before the appointment time.
      •    Appointments canceled/rescheduled with less than 48 hours’ notice will result in a 50% charge of the scheduled service.
      •    No-shows and frequent cancellations may result in permanent denial of service or require prepayment in full.
      •    A 10-minute grace period is allowed for late arrivals; after this, the appointment will be canceled and subject to late fees or forfeited.
      •    Disputing valid charges without cause (e.g., initiating a false chargeback) is considered theft of service and may result in legal action, including court proceedings or police involvement.
  
  ⸻
  
  7. Release of Liability & Legal Indemnification
  
  By signing below, I agree to release and hold harmless Shakiyla Trevett (Shay Trevett) and Lunar Esthetix LLC from all liability, claims, damages, or demands—whether known or unknown—that may arise in connection with services provided, including any reactions or injuries sustained from treatments, products, tools, or failure to disclose relevant information.
  
  I understand this waiver shall be governed by the laws of the State of New York, and any disputes arising from services rendered shall be resolved within the jurisdiction of Broome County, NY.
  
  ⸻
  
  8. Acknowledgment of Consent & Authorization
  
  By signing below—both electronically and/or manually—I confirm that:
      •    I have received and understand all information regarding services.
      •    I understand all fees and policies associated with treatment.
      •    I authorize the Service Provider to perform services at my request.
      •    I release the Service Provider and all associated persons/entities from liability.
      •    I voluntarily enter into this agreement and understand its legal implications.
- Please Type Your Name:*
  First and Last Name
- Please Sign Your Name*
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New Client Intake, Consent and Waiver Form

Lunar Esthetix is located:

About You

Service Preferences

Medical History

Your Treatment

Consent, Liability and Policy Waiver