Consent and Intake Form E33 Esthetics

General Intake Form - E33 Esthetics LLC

Disclaimer: Thank you for your interest in being a client of E33 Esthetics! This form is used to collect information about new clients and used for internal purposes only. The information you provide is confidential and will be treated accordingly. This information will not be shared or spoken about outside of this treatment room. As with any cosmetic procedure, the goal of a facial treatment is improvement, not perfection. I understand that my results may not be perfect In the case of a facial treatment, the number of treatments necessary and results experienced will vary among individuals and the areas being treated. I understand that the practice of cosmetology and esthetics is not an exact science and that no specific guarantees can or have been made concerning the expected result. Please answer all questions with honesty to the best of your ability. These forms help create a better understanding of you, your needs and your skin. By signing below you recognize that to reach your skin goals - communication between you and your esthetician is imperative and consistency is key.

Name

Street Address

City

State

Zip Code

Email

example@example.com

Phone

Format: (000) 000-0000.

How did you hear about us

Signature

Date

Are you currently under a physicians care for a skin condition or other problem?

Are you pregnant or do you plan on becoming pregnant?

Are you currently taking birth control? If yes, what type?

Are you taking hormone replacement medication? If yes, what type?

Are you curretly under a lot of stress?

Have you been diagnosed with cancer? If yes, what is/was your diagnosis and how long ago

Do you have any known allergies? If yes what type? (Note that allergies to almonds aspirin citrus benzoyl peroxide eggs mushrooms and sulfur may be relevant to this treatment)

Are you currently taking any medications? If yes what type ?

Have you ever taken accutane?If yes, when was your last dose?

Do you experience acne? If yes, where?

Are you currently having your menstrual period if you menstruate?

What best fits your skin type?

What are your main concerns regarding your skin? Breakouts, acne, whiteheads/blackheads, uneven tone, uneven texture, dull skin, dry skin, oily skin, wrinkles, rosacea, redness, sensitivity etc?

When you go out in the sun, do you:

Have you seen a dermatologist in the last year? If yes for what reason

Do you currently use or have you ever used any of the products listed below? - Differin - Accutane- Adapalene - Isotretinion - Retin-A / Stieva-A - Scrub/Peel - Tretinoin / Avita - Other:

Have you recieved any neurotoxin (botox, dysport, etc.) or filler in the areas of treatment recently? If yes please specify.

Have you received any advanced cosmetic services recently (lasers, peels, collagen induction therapy/microneedling)? If yes what type and how long ago?

By signing this form, the client agrees to the following: I understand, have read, and completed this intake form truthfully and agree to inform E33 Esthetics LLC (Emily Herman) of any changes in the above information. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I understand that I may have some discomfort, redness, swelling, itching, irritation, skin peeling, or flaking after a facial treatment. If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I also understand that a 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.

Because certain treatments should not be performed under certain medical conditions, I understand that the esthetician reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which facial treatments are contraindicated. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the esthetician's part should I fail to do SO.

It is my decision to have this treatment and I certify that I have read and have full understanding of the above consent. I have been given ample opportunity for discussion and all of my questions have been answered to my satisfaction. I hereby consent to the facial treatment procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures. Neither E33 Esthetics LLC nor Emily Herman are responsible for any injury, allergic reactions, or any skin abrasions as a result of the services performed on me.

Signature

Date

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