SKIN NOLA
CLIENT INTAKE AND TREATMENT CONSENT FORM
Full Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell
Format: (000) 000-0000.
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Preferred Method of Contact
Phone Call
Text Message
Email
Emergency Contact:
Name
Relationship
Phone Number
Format: (000) 000-0000.
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Medical History:
Please list any illnesses or medical conditions that you are currently being treated for by a medical professional
List any medications and/or supplements that you are currently taking
Are you currently pregnant or breast feeding?
Yes
No
Have you had recent dental procedures/oral surgery in the last 2 weeks?
Yes
No
If yes, please specify:
Recent Surgery:
Have you had any surgical procedures in the last 6 months?
Yes
No
If yes, please specify:
Have you been prescribed Accutane (Isotretinoin) within the last 12 months?
Yes
No
Are you currently using Retin-A, Retinol, Tretinoin or prescription topicals?
Yes
No
If yes, how often?
If discontinued, when?
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Current Skin Care Regimen:
Please list the skincare products you currently use and how often:
Previous Skincare Treatments:
Have you previously received any of the following treatments?
Chemical Peels
Botox / Neuromodulators
Microdermabrasion
Dermal Fillers
Microneedling
other skin resurfacing treatments
Laser Treatment
Other
If yes, when was your most recent treatment?
What are your skin care goals?
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Client Acknowledgment
Please carefully review each statement below and check the box to confirm your understanding and acknowledgement. By selecting each box, you indicate that you have read and agree to the following statements.
I understand that Skin Nola is not a medical practice and that the services provided are cosmetic in nature and not a substitute for medical diagnosis or treatment.
I understand that aesthetic treatments may be contraindicated under specific medical conditions and I affirm that I have disclosed all known medical conditions and answered all health history questions truthfully.
I agree to inform my aesthetician of any changes to my medical history, medications, or skin condition prior to each treatment.
I understand that results from aesthetic treatments vary from person to person and that guarantees have been made regarding the outcome of any treatment.
I understand that I must immediately inform the aesthetician if I experience discomfort during a treatment so that the procedure may be adjusted.
I understand that the aesthetician reserves the right to refuse or discontinue treatment if a condition appears contraindicated or if a client's conduct is inappropriate.
I understand the potential risks associated with aesthetic treatments and give consent to receiving treatment.
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Treatment Consent
I acknowledge this consent form and I agree that Skin Nola and the aesthetician performing my service shall not be held liable for any adverse reactions or complications that may occur when all pre-treatment instructions and full medical disclosures have been followed. I certify that I have read and fully understand the above paragraphs and that I have sufficient opportunity for discussion to have any questions answered. By checking the boxes above and signing below, I acknowledge that I have read, understand and agree to all of the above statements and consent to treatment.
Photography Consent
I consent to photographs being taken for treatment documentation and progress evaluation purposes only. These images will remain confidential and part of my client record.
Yes
No
Client Name (Print)
Client Signature
Date
-
Month
-
Day
Year
Date
Referred by:
Google
Instagram
Facebook
Family/Friend
Skin Nola Website
Existing Skin Nola Client
Physician/Dermatologist
Local Business
Event
Other
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