Earthbound Skin Spa Client Intake & Consent

Earthbound Skin Spa Client Intake & Consent

Texas-compliant medical, skin care, and consent form. Please complete all relevant sections accurately.
Personal Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
City
State
Occupation
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Current Medications (include birth control, aspirin, blood thinners, eye drops, steroids, weight loss meds)
List all allergies (including latex)
Do you smoke?
Alcohol per week (number of drinks)
Are you an ex-smoker?
Caffeine per day (cups)
Currently pregnant or nursing?
Medical Conditions (check all that apply)

Other
If you checked 'Herpes Simplex (cold sores)', when was your last outbreak?
Previous surgeries (include dates)
Skin History & Assessment
Have you seen a dermatologist?
If yes, what for?
Last menstrual period (date)

MonthDayYear
Date
Have you had Botox or Fillers?
Have you used Accutane?
If yes, how long ago?
Have you used Retin-A, glycolic, or salicylic acid?
Current skincare products
Have you ever had a bad reaction to skincare?
If yes, please provide details:
Have you had a chemical peel?
If yes, did you have an adverse reaction?
Do you use sunscreen daily?
Do you use wax or depilatories on your face?
When was your last tan or tanning bed use?
Skin concerns (check all that apply)

Other
Do you or a family member have a history of skin cancer?
Fitzpatrick Skin Type Assessment
Eye Color
Natural Hair Color
Skin Tone
Sun Reaction
Tanning Ability
Total Fitzpatrick Score
Skin Type
Treatment(s) Requested

Other
General Treatment Informed Consent & Liability Acknowledgment
I acknowledge and agree to the following (initial each line)
Client Signature
Date

MonthDayYear
Date
Staff Witness Signature
Staff Witness Date

MonthDayYear
Date
HIPAA Notice of Privacy Practices (Condensed)
HIPAA NOTICE OF PRIVACY PRACTICES (Condensed - Full notice available upon request)

This notice describes how medical information about you may be used/disclosed and how you can access it.

OUR COMMITMENT: Earthbound Skin Spa is committed to protecting your medical information. We are required by law to: (1) keep medical information private, (2) provide this Notice, and (3) follow the terms herein.

HOW WE USE/DISCLOSE YOUR INFORMATION:
• Treatment & Care: Disclosure to doctors, nurses, staff, specialists, and family members involved in your care
• Operations: Performance evaluation, quality improvement, appointment reminders, treatment recommendations
• Emergency Care: Disclosure to other healthcare providers as needed
• Other Uses: Only with your written authorization (revocable at any time)

YOUR RIGHTS:
• Review/copy medical records (written request required, fees may apply)
• Request amendments (written request with reason required)
• Request confidential communications (specific method/location)
• Receive copy of this Privacy Notice
• File complaints (written, no retaliation)

RECORD RETENTION: Medical records retained for minimum 7 years per Texas law.

CHANGES: We reserve the right to change this Notice at any time.
I acknowledge receipt and understanding of the HIPAA Notice of Privacy Practices.
Client Signature (HIPAA)
Date (HIPAA)

MonthDayYear
Date
Image of your State Issued ID
Spa Policies & Agreements
APPOINTMENTS: Schedule as far in advance as possible. You will receive confirmation email/text 48 & 24 hours prior. Arrive 10 minutes early for paperwork. Lateness (>10 min) may result in shortened treatment time. FAQ: https://www.earthboundskin.com/faq

CANCELLATION & NO SHOW: 48-hour advance notice required. Credit card guarantee required. $50 fee if cancelled/rescheduled appointment goes unfilled. Full cost charged if appointment cannot be filled, regardless of reason (no exceptions). Vouchers forfeit entirely without 48-hour notice.

REFUND POLICY: No refunds for services. Products refundable within 7 days if unused in original packaging with receipt (issued as Earthbound credit only).

GRATUITY: Not included in prices; discretionary. Accepted: cash, check, credit card at checkout.

GIFT CERTIFICATES: Non-refundable; cannot be redeemed for cash or gratuities.

TREATMENT EXPIRATION: Service packages/pre-paid treatments expire 12 months from purchase date.

By signing below, I agree to all policies and terms stated above.
Client Signature (Policies)
Date (Policies)

MonthDayYear
Date
Before/After Photo Consent
I authorize Earthbound Skin Spa to take before/after photos for treatment outcome assessment only. Photos will not be displayed without separate written consent.
Client Signature (Photo Consent)
Date (Photo Consent)

MonthDayYear
Date
Laser/Radiofrequency Treatment Policy
For laser or RF treatments, the treatment area must be cleanly shaved the night before the appointment. $75 technician shaving fee applies if not shaved.
I acknowledge the laser/radiofrequency treatment shaving policy.
Client Signature (Laser/RF Policy)
Date (Laser/RF Policy)

MonthDayYear
Date
Spa Etiquette
Please silence cellphones. Children 14+ welcome by appointment only
Business Rules and Regulations Signature
Final Acknowledgment
I certify all information provided is complete and accurate.
I understand withholding information may affect treatment safety and results.
I consent to treatment under the supervision of Earthbound Skin Spa's Medical Director.
Client Name (Print)
Client Signature (Final)
I acknowledge the Business Rules and Regulations
Date (Final)

MonthDayYear
Date
Should be Empty:

Earthbound Skin Spa Client Intake & Consent

Personal Information

Medical History

Skin History & Assessment

Fitzpatrick Skin Type Assessment

General Treatment Informed Consent & Liability Acknowledgment

HIPAA Notice of Privacy Practices (Condensed)

Spa Policies & Agreements

Before/After Photo Consent

Laser/Radiofrequency Treatment Policy

Spa Etiquette

Final Acknowledgment