INTAKE + CONSENT FORM
Client Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Shipping Address
*
Street Address
Street Address Line 2
City
State/ Province
Postal / Zip Code
Please take a moment to answer the following questions
How did you hear about Skin by Kinsey? If you were referred by someone, please tell us who.
*
What would you like to achieve from your visit?
What are your current skin concerns?
*
Rows
Please select
Acne
Aging
Texture
Pigmentation
Pore Size
Scarring
Redness
Elasticity
Other
What do you do for work?
What skin care products do you currently use?
*
Cleanser
Toner
Antioxidant Serum
Eye Cream
Spot Treatment
Moisturizer
Sunscreen
Vitamin C Serum
Face Oil
Retinol/AHAs/BHAs
Other
Have you used Retin-A, Renova, Adapa-lene, Accutane, Differen, or acids (AHAs or BHAs), or Dermatologist prescribed topicals within the last week? Please specify
*
Do you have any allergies or sensitivities to cosmetics, food, or drug?
*
Are you currently taking any medications, vitamins or supplements?
*
Yes
No
If so, please list them:
Please check if you are affected by or have any of the following
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Anemia
Neurological Disorders
Diabetes
Hemophilia
Cancer
High Blood Pressure
HIV/AIDS
Pace Maker
Herpes Simplex (Cold Sores)
Sinus or Respiratory Issues
Psoriasis
Skin Disease
Staph Infection
Lupus
Eczema
Keloid Scarring
Cancer
Metal Implants
Rosacea
Bruise Easily
Migraines/Headaches
Epilepsy or Seizures
Gut Imbalances
Claustrophobia
Hormone Disorder
None
Are you pregnant, nursing, or trying to conceive?
*
Do you use birth control pills, shot, or IUD? If so, which kind?
*
What is your goal in working with an Esthetician?
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Regular in-office treatments
Receive and follow an esthetician guided homecare routine
Both
Do you prefer a silent appointment?
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Yes
No
No Preference
Are you okay with photos/videos being posted of your service?
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Yes
No
Yes, but block out eyes
Terms & Conditions
I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. By signing this I hold my skin care specialist and Skin by Kinsey harmless and nameless from any liability that may result from this treatment.
*
I understand and agree to the terms and conditions
Policies
By agreeing to our policies, you understand that this appointment at Skin by Kinsey is reserved exclusively for you and requires a 24-hour notice for cancellation or rescheduling. Canceled or rescheduled appointments within 24 hours will incur a 100% cancellation fee. No-shows or late arrivals (more than 15 minutes) that require the appointment to be rescheduled or cancelled will also be charged 100% of the service price. By booking and entering your card information, you are authorizing Skin by Kinsey to charge your card for any cancellation, rescheduling, and/or no show fees that incur. Fees must be paid before any future appointments can be scheduled.
By submitting this form, you acknowledge and agree that this document serves as proof of your consent and participation. Any attempt to dispute the transaction will be met with this evidence, confirming that you have willingly filled out and agreed to the terms stated.
*
I understand and agree to the cancellation policies
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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