• New Client Intake Form

    This form allows me to safely and thoughtfully customize your treatment based on your skin, health history, and goals. All information is kept confidential, securely stored, and used solely for treatment-related purposes. You will only need to complete this form once, or again if it has been more than one year since your last visit. Please note, the studio is located on the second floor and requires the use of stairs. If you have accessibility needs, please reach out prior to your appt so we can discuss accomodations. Please allow 15-30 minutes to complete this form.
  • Today’s Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are your currently pregnant or breastfeeding?*
  • Are you currently using HRT (hormone replacement therapy) for perimenopause or menopause symptoms?*
  • Are you currently using any topical prescription skin creams or gels? (examples: tretinoin, adapalene, metronidazole, clindamycin)*
  • Have you ever been formally diagnosed with Acne by a Dermatologist?*
  • Have you ever taken prescription Accutane?*
  • Do you experience any of the following?*
  • We may incorporate essential oils or essences of fresh herbs/flowers to elevate your treatment. Please indicate if you are allergic or sensitive to any of the ingredients listed below.*
  • Many common ingredients in skincare products are derived from, or contain some of the ingredients listed below. Please indicate if you are ALLERGIC to or INTOLERANT or any of the ingredients listed below.*
  • How would you rate your current stress level?*
  • How much sleep do you get on an average night?*
  • How often do you wear facial sunscreen?*
  • Which best describes how your skin reacts to sun exposure? If unsure, choose the option that most closely matches your experience.*
  • Ethnicity/Cultural Background (optional); check all that apply
  • How would you describe your skin? (check all that apply)*
  • What are your skin concerns? Check all that apply*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Have you ever had a full skin check by a dermatologist or primary care provider?*
  • Are you currently under the care of a Dermatologist (MD)?*
  • Have you received BOTOX or FILLER treatments in the last TWO months?*
  • Have you had any facial waxing in the last 5-7 days?*
  • Have you had any CHEMICAL PEELS in the last FOUR weeks?*
  • Do you have a history of any of the following skin conditions? This information is important in the context of your skin analysis and necessary in recommending treatments and products that will be safe and effective.*
  • Medical conditions (check all that apply) This information is important as some medical conditions require adjustments in the treatment room, or can be contraindications to receiving a treatment or can make your skin more susceptible to unwanted side effects.*
  • How much would you be willing to consider spending on a home care product that would help to treat or improve your top skin concerns?*
  • How much time are you willing to spend on your AM/PM skincare routine?*
  • Are you currently using any at-home skin devices?*
  • Have you ever had any of the following SKIN TREATMENTS*
  • Internal-use photography consent*
  • Marketing / Educational Photo & Video Consent Level*
  • New Client & Professional Boundaries Policy

    The Complexion Cottage is a private, appointment-only skincare studio. All new clients are required to complete intake and consent forms prior to their first appointment so that I can determine whether the requested service is appropriate and within my scope of practice.

    For the comfort and safety of both client and provider, professional boundaries are maintained at all times. I reserve the right to decline, modify, discontinue, or refuse future services due to contraindications, inappropriate or threatening behavior, boundary violations, failure to follow studio policies, or any circumstance in which I am unable to safely or appropriately provide the requested service.

    The Complexion Cottage does not accept walk-ins. All services must be scheduled in advance through the studio’s booking process.

  • Client Contraindication & Communicable Conditions Acknowledgement

    I understand that certain skin conditions, infections, or health factors may contraindicate or require modification of esthetic treatments.

    I confirm that I do not currently have any active, contagious, or untreated skin conditions including, but not limited to:

    Herpes simplex (cold sores)
    Human papillomavirus (HPV) / warts
    Impetigo
    Conjunctivitis (pink eye)
    Fungal infections (e.g., ringworm)
    Scabies
    Lice

    Any open wounds, lesions, or unexplained skin eruptions


    I understand that if any of the above conditions are present, my service may be postponed or modified for the safety of myself and others.

    I further confirm that I have disclosed all relevant health information, including medications, skin conditions, allergies, and recent treatments, to the best of my knowledge. I agree to inform my esthetician of any changes to my health or skin prior to each appointment.

    I understand that failure to disclose pertinent information may increase the risk of adverse reactions, and I accept responsibility for any outcomes resulting from incomplete or inaccurate disclosure.

    I understand that upon in-person evaluation, my esthetician reserves the right to refuse or modify treatment based on the condition of my skin, regardless of any information provided prior to the appointment.

    If you have any questions about the status of a current or recent infection, skin condition or wound, please contact your Esthetician at least 24 HOURS prior to your scheduled appointment in order to be cleared for treatment.

     

    By signing below, I acknowledge and agree to the above statements.

  • Wellness Policy

    To protect the health of all clients, we kindly ask that you reschedule your appointment if you are feeling unwell in any way.

    If you have had a fever, vomiting, or diarrhea in the past 24 hours, or have had recent known exposure to illness, your appointment must be rescheduled.

    Failure to comply with this policy may result in refusal of services on the day of your appointment.

  • Cancellation & Late Arrival Policy

    At The Complexion Cottage, appointment times are reserved exclusively for you. We understand that life happens, and we kindly ask for as much notice as possible if you need to reschedule or cancel your appointment.

    Cancellation
    Cancellations made with less than 24 hours’ notice will be subject to a 50% cancellation fee based on the cost of the scheduled treatment. This policy helps us manage our schedule and accommodate other clients who may be waiting for openings.

    No-shows or same-day cancellations may be charged the full cost of the scheduled service.

    Late Arrival
    To ensure that each client receives the full benefit of their treatment, we ask that you arrive on time. If you arrive more than 10 minutes late, we may need to adjust your treatment or reschedule your appointment. Please note that late arrivals may result in a shortened service time out of respect for other scheduled clients, but the full service fee will still apply.

     

  • Payment & Refund Policy

    Payment is due at the time of service. Refunds are not offered for completed treatments, but credit toward future services may be issued after discussion with, and at the discretion of the esthetician.

    By signing below, I acknowledge and agree to the above 3 policies.

  • Client Responsibility and Reaction Policy

    At The Complexion Cottage, we take every precaution to ensure safe and effective treatments, using high-quality products and professional protocols. However, each individual’s skin may react differently, and we cannot guarantee specific results. By receiving services, you acknowledge and accept that The Complexion Cottage is not liable for any unexpected skin reactions that may occur.

    It is essential that all clients provide complete and accurate information on their intake forms, including details about medications, health conditions, allergies, and skincare products. The esthetician cannot be responsible for treatment outcomes if relevant information is withheld or inaccurately reported.

    Failure to fully disclose this information may result in adverse reactions or less effective results. In such cases, The Complexion Cottage is not responsible for any negative outcomes stemming from incomplete or incorrect client-provided information.

  • Refusal of Service or Product Clause

    At The Complexion Cottage, your skin’s health and safety are our highest priority. If, at any time, the esthetician determines that a selected product or procedure may compromise the integrity of your skin, affect the quality of the outcome, or pose a risk to your overall skin health, the esthetician reserves the right to modify the treatment plan, substitute products, or discontinue the service entirely.

    This decision will be made with your best interest in mind. If a service is terminated for these reasons, any refunds will be issued promptly and at the sole discretion of the esthetician, based on the circumstances of the session and the extent of services rendered.

    We appreciate your trust and understanding as we prioritize your skin’s well-being.

  • Post-Treatment Care Acknowledgment

    At The Complexion Cottage, we are committed to helping you achieve the best possible results from your treatment. Proper aftercare plays a vital role in your skin’s healing process and the overall success of your service.

    ~ You may receive specific post-treatment care instructions tailored to your service.


    ~ You understand that following these instructions is essential to achieving optimal results and minimizing the risk of irritation or complications.


    ~ You accept responsibility for adhering to all post-care guidelines provided.


    The Complexion Cottage is not responsible for adverse outcomes resulting from failure to follow post-treatment recommendations or from using unapproved products on the treated area.

    By signing below, I acknowledge and agree to comply with the above 3 policies.

  • Client Acknowledgment & Release of Liability

    By signing below, I confirm that all aesthetic services I receive at The Complexion Cottage are performed by a duly licensed esthetician (license information is available on our GlossGenius booking site). I understand that these services involve the use of professional products, tools, and techniques and that, despite all reasonable precautions, there is an inherent risk of irritation, allergic reaction, injury, illness, or other harm. I voluntarily accept and assume all such risks and hereby release, discharge, and hold harmless The Complexion Cottage, its owner, employees, contractors, and affiliates from any and all liability, claims, or damages arising out of or related to any harm, injury, or illness that may occur before, during, or after my treatment.

  • Diagnosis & Referral Policy

    Statement:

    I understand that my esthetician is not a medical professional and does not diagnose medical conditions or diseases. Any information, guidance, or recommendations provided are for cosmetic and educational purposes only.

    If my esthetician identifies any condition that may require medical evaluation, I understand that I may be referred to a licensed healthcare provider, such as a dermatologist or primary care provider, for further assessment.

    I acknowledge that it is my responsibility to seek medical care when appropriate and to follow up on any referrals provided.

    I understand and accept that my esthetician reserves the right to refuse any current or future treatment until I have been evaluated by a medical professional.  

  • Ongoing Consent Acknowledgment

    Statement:

    I understand that my skin condition, health status, and medications may change over time and may affect the safety and effectiveness and intended outcomes of aesthetic treatments.

    I agree to inform my esthetician of any changes to my health, medications, skin condition, or lifestyle factors prior to each appointment.

    I give my ongoing consent to receive aesthetic treatments and understand that services may be modified, postponed, or declined based on my skin condition or any contraindications present at the time of service.

    I understand that I may ask questions and withdraw my consent at any time prior to or during treatment.  I further acknowledge that withdrawing consent during a treatment does not negate or invalidate any prior authorizations, informed consents, or waivers for any services already performed  or for the portion of the treatment that has been completed.  

    By signing below, I acknowledge that I have read, understand and agree to the terms of the 3 policies and acknowledgements listed above.

  • Lastly, by signing below, I acknowledge that I have read, understand, and agree to all policies listed above. 

    I understand that my signature on these policies, waivers, and consent forms will remain valid and in effect for all future services unless and until I revoke or update them in writing.  Revoking or updating consent only applies to future services not yet rendered, and can not be applied retroactively to previously completed or partially completed treatments or services, nor does it void consents completed at the time of current or past treatments. 

    Revocation or updated consent applies only to any services, consultations or treatments performed after the date that the written revocation is completed.  I understand that any false, misleading, or incomplete information provided in a revocation request, including attempts to misrepresent services already performed, may result in the revocation being deemed invalid and may release The Complexion Cottage from liability to the extent permitted by law.

    I am also aware that I can access a copy of these policies by visit www.thecomplexioncottage.com or by contacting my esthetician directly at any time. 

    I further understand that failure to adhere to these policies may result in my termination as a client at The Complexion Cottage.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: