Facial - Client Intake Form

Facial - Client Intake Form
Client Information
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Treatment Selection
Which service(s) are you receiving today?
Health History
Have you ever had a facial treatment before?
If yes, when was the last treatment?
Have you ever experienced a reaction to a facial treatment or skincare product?
If yes, please specify:
Have you received any of the following within the past 2 weeks? (select all that apply)
Are you currently using any of the following? (select all that apply)
Are you currently pregnant or breastfeeding?
Have you ever been diagnosed with skin cancer or any other skin condition that may affect the treatment?
If yes, please specify:
Medical Information
List any allergies: (including medications, latex, skincare products, fragrances, etc.)
List any illnesses, medical conditions, or treatments you are receiving from a physician:
List all medications and supplements you are currently taking:
Skin Assessment
How would you describe your skin?
What are your primary skin care concerns? (select all that apply)

Other
If other, please specify:
What is your current skincare routine? (select all that apply)

Other
If other, please specify:
Client Acknowledgments
I understand there are risks associated with receiving facial treatments. I understand possible side effects may include temporary redness, sensitivity, dryness, flaking, peeling, tightness, mild swelling, bruising (from extractions), or temporary breakouts as my skin adjusts following treatment. In rare cases, allergic reactions, infection, pigmentation changes, or scarring may occur.

I understand that allergic reactions may occur even if I have previously received facial treatments or used similar products without complications.

I understand that my skin type, skin condition, lifestyle, medications, home skincare routine and adherence to aftercare instructions may affect my results, and that no specific outcome or duration of results can be guaranteed.

I understand that if my esthetician determines it is not safe to perform this service due to a medical condition, skin irritation, active infection, contraindication, recent procedures, medication use, or any other safety concern, the service may be modified, postponed, or refused.

I understand the importance of accurately disclosing my medical history, medications, allergies, recent cosmetic procedures, and skincare product usage, including the use of retinoids, exfoliants, or prescription acne medications.

I understand that I must follow all post-treatment instructions provided by MaiBeautyyCo, including the use of sunscreen, avoiding excessive sun exposure, heat, strenuous exercise, swimming, and any products or activities my esthetician advises against for the recommended period.

I understand that if I experience excessive redness, swelling, blistering, severe pain, signs of infection, or any unexpected reaction following my appointment, I should contact MaiBeautyyCo immediately and seek medical attention if necessary. Any medical evaluation or treatment will be at my own expense.

I agree to notify my esthetician immediately if I experience discomfort during the treatment.

By initialing below, I acknowledge that I have read, understand, and agree to all of the information provided above regarding the risks, contraindications, possible side effects, aftercare instructions, and expectations associated with facial services.
Client Initials:
Consent & Release
I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that withholding or providing inaccurate medical or skincare information may increase the risk of complications during or after treatment.

I understand that while every reasonable precaution will be taken to ensure my comfort and safety, no guarantees have been made regarding the results or longevity of this treatment.

I voluntarily consent to receive the selected facial treatment(s) and any appropriate modifications deemed necessary by MaiBeautyyCo to safely address my skin concerns.

I understand that my treatment plan may be adjusted during my appointment based on my skin assessment and any contraindications identified by my esthetician.

I understand that my esthetician may decline or postpone treatment if it is determined that performing the service may not be safe due to a contraindication, illness, medication, skin condition, or other health-related concern.

I release and hold harmless MaiBeautyyCo and its owner, Mariah Cruz, from liability arising from the ordinary and known risks associated with facial treatments, except where prohibited by law or in cases of gross negligence or willful misconduct.

I understand that this consent will remain valid for future facial services unless my medical history changes or this agreement is replaced with an updated version.

I understand that it is my responsibility to notify MaiBeautyyCo before each appointment of any changes to my medical history, medications, allergies, pregnancy status, skincare products, or recent cosmetic procedures.

I acknowledge that I have had the opportunity to ask questions regarding this treatment, that my questions have been answered to my satisfaction, and that I fully understand the information provided above.

By signing below, I confirm that I have read this entire consent form, understand the risks, potential benefits, contraindications, possible side effects, and aftercare requirements associated with facial treatments, and voluntarily consent to receive the selected facial service(s).
Signature
Date

MonthDayYear
Date
Photo & Video Release (Optional)

MaiBeautyyCo may take photographs and/or videos before, during, or after your treatment to document your progress, monitor treatment results, create content, and showcase services.
Please select ONE of the following:
I consent to photographs and/or videos being taken for treatment documentation and my confidential client record only. These images/videos will not be used for marketing or shared publicly.
I consent to photographs and/or videos being taken and authorize MaiBeautyyCo to use them for marketing, advertising, educational, and promotional purposes.

This includes, but is not limited to:
- Social Media (Instagram, Facebook, TikTok, Pinterest, etc)
- Website & Online Portfolio
- Printed Marketing Materials
- Before-and-After Galleries
- Digital Advertisments
- Email Marketing
- Educational & Informational Content
- Future Promotional Materials
I understand that these photographs and/or videos may be edited or cropped for presentation purposes but will not be altered in a misleading manner. I understand that my name and other identifying personal information will not be disclosed without my separate permission.
I do not consent to photographs or videos being taken during my appointment.

I understand that my decision regarding photographs and videos is completely voluntary and will not affect my ability to receive the treatment or the quality of services provided by MaiBeautyyCo.
Client Initials:
Should be Empty:

Facial - Client Intake Form

Client Information

Emergency Contact

Treatment Selection

Health History

Medical Information

Skin Assessment

Client Acknowledgments

Consent & Release

Photo & Video Release (Optional)