NEW CLIENT INTAKE & CONSENT FORM
Cosmetic Skin Treatments & Esthetic Services
Client Information
Name:
Date of Birth:
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Mes
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Día
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Fecha
Phone:
Format: (000) 000-0000.
Email:
ejemplo@ejemplo.com
Date of Appointment:
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Mes
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Día
Año
Fecha
Esthetician:
Emergency Contact:
Emergency Phone:
Format: (000) 000-0000.
Medical History & Health Disclosure
To ensure your safety, please answer the following questions honestly. Failure to disclose medical conditions or medications may increase your risk of injury during treatment.
Are you currently experiencing any of the following?
Fever or illness
Open cuts, wounds, abrasions, or sores
Sunburn or windburn
Skin irritation
Active rash
Cold sores (Herpes Simplex Virus)
Ringworm
Warts in the treatment area
Cellulitis
Impetigo
Active fungal infection
Active bacterial infection
Undiagnosed skin lesions
None of the above
If yes, please explain:
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Skin Conditions
Do you currently have or have you been diagnosed with any of the following?
Sensitive skin
Rosacea
Eczema
Psoriasis
Dermatitis
Thin or fragile skin
Broken capillaries
Keloid scarring
Easy bruising
Varicose veins
Skin cancer
Suspicious skin lesions
None
Additional information:
Medical Conditions
Please check all that apply.
Diabetes
Bleeding disorder
Hemophilia
Poor circulation
Peripheral neuropathy
Lupus
Autoimmune disorder
Cancer
Currently receiving chemotherapy
Currently receiving radiation therapy
HIV/AIDS
Organ transplant
Immune suppression
Epilepsy or seizure disorder
Other:
Pregnancy & Hormonal Status
Pregnant
Weeks:
Breastfeeding
Menopause
Hormone replacement therapy
Polycystic Ovary Syndrome (PCOS)
Currently menstruating
None
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Prescription Medications
Are you currently taking or using any prescription medications?
No
Yes (please discuss with esthetician prior to appointment)
Please check any that apply:
Medications
Accutane (Isotretinoin)
Retin-A (Tretinoin)
Adapalene (Differin)
Tazarotene (Tazorac)
Other prescription medications:
Prescription acne medications
Topical steroids
Blood thinners
Photosensitizing medications
When was the last time you used or took the above indicated medication?
Over-the-Counter Skin Care Products
Within the past 7 days, have you used any of the following on the treatment area?
Skin Care Products
Retinol
Glycolic Acid
Lactic Acid
Salicylic Acid
Vitamin C Serum
Benzoyl Peroxide
Enzyme exfoliants
Facial or body scrub
None
Recent Cosmetic Procedures
Have you received any of the following within the past 12 weeks?
Cosmetic Procedures
Botox
Dermal fillers
Chemical peel
Microneedling
Dermaplaning
Microdermabrasion
IPL
Laser resurfacing
Laser hair removal
Radiofrequency treatment
Plasma fibroblast treatment
Cosmetic surgery
None
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If yes, date performed:
Have you ever been seen by a dermatologist, if so please list the provider's name or practice location:
Are you currently seeing this provider?
Yes
No
Allergies
Please indicate any known allergies.
Allergies
Beeswax
Fragrance
Pine resin (Rosin)
Essential oils
Latex
Adhesives
Aloe
Preservatives
Tea Tree
Other:
No known allergies
Lifestyle Factors
Within the last 48 hours have you:
Lifestyle Factors
Been sunbathing
Consumed excessive caffeine
Used a tanning bed
Recently shaved the treatment area
Applied self-tanner
Recently waxed the treatment area
Exercised immediately before appointment
None
Consumed alcohol
Previous Esthetic Treatment History
Have you received any professional esthetic or cosmetic skin treatments before?
Have you received any professional esthetic or cosmetic skin treatments before?
Yes
No
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If yes, please check any you have received:
Waxing Services
Chemical Peels
Eyebrow Tinting
Eyebrow Lamination
Nano Needling
Microneedling
Dermaplaning
Microdermabrasion
Laser/IPL Treatments
Facials or Advanced Skin Treatments
Have you ever experienced any adverse reactions after a cosmetic skin treatment?
Adverse Reactions
Excessive redness
Swelling
Burning sensation
Skin lifting
Bruising
Scarring
Adverse Reactions
Allergic reaction
Breakouts
Infection
Hyperpigmentation or discoloration
Prolonged sensitivity
None
Other:
Please explain:
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Client Acknowledgment & Informed Consent
I understand that cosmetic skin treatments and esthetic services are designed to improve the appearance and condition of the skin; however, results vary from person to person and cannot be guaranteed.
I understand that all cosmetic skin treatments involve inherent risks, including but not limited to temporary redness, irritation, sensitivity, swelling, dryness, discomfort, allergic reactions, changes in pigmentation, breakouts, infection, or other unexpected skin reactions.
I understand that an esthetician, as defined under Alabama Code § 34-7A-1, is a professional performing treatments like facials, body hair removal/waxing, and general skin care. I understand that information and recommendations provided by JHL SPA, LLC and its estheticians are for cosmetic purposes only and are not intended to be medical advice, diagnosis, or medical treatment. I acknowledge that JHL SPA, LLC and its estheticians are not medical professionals and do not provide medical advice and that any medical concerns should be addressed with an appropriate healthcare professional.
Waxing Services
I understand that waxing removes hair from the follicle and may cause temporary redness, swelling, tenderness, sensitivity, bruising, pinpoint bleeding, ingrown hairs, folliculitis, allergic reactions, pigmentation changes, or skin lifting.
I understand that waxing risks may be increased by certain medications, skincare products, hormonal changes, sun exposure, or recent cosmetic procedures.
Chemical Peel Services
I understand that chemical peels involve the application of professional exfoliating solutions to improve skin texture, tone, and appearance.
I understand that chemical peels may cause temporary redness, warmth, tingling, dryness, tightness, peeling, flaking, sensitivity, irritation, breakouts, pigmentation changes, allergic reaction, scarring, or infection.
I understand that sun exposure and failure to follow pre-treatment and post-treatment instructions may increase the risk of complications.
Eyebrow Tinting
I understand that eyebrow tinting involves applying cosmetic color products near the eye area and may result in temporary staining, irritation, redness, itching, swelling, sensitivity, or allergic reaction.
I understand that patch testing may be recommended and that previous tolerance of a product does not eliminate the possibility of developing a reaction.
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Eyebrow Lamination
I understand that eyebrow lamination uses chemical solutions to restructure and soften brow hair.
I understand that possible risks include dryness, brittleness, irritation, redness, sensitivity, allergic reaction, or changes to the condition of the brow hair.
I agree to follow all recommended aftercare instructions to maintain the health and appearance of my brows.
Nano Needling
I understand that nano needling is a cosmetic procedure intended to improve product absorption and enhance the appearance and texture of the skin.
I understand that possible reactions may include temporary redness, sensitivity, dryness, tightness, irritation, inflammation, breakouts, uneven pigmentation, allergic reaction, bleeding, or infection.
I understand that individual results vary and multiple treatments may be recommended to achieve desired results.
Release of Liability
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I understand that no guarantees have been made regarding the results of this treatment. I agree to follow all pre-treatment and post-treatment instructions provided by my esthetician.
To the fullest extent permitted by applicable law, I voluntarily assume the ordinary risks associated with the services provided by JHL SPA, LLC and release the esthetician and business from liability for adverse outcomes resulting from inherent treatment risks, incomplete or inaccurate medical disclosures, or failure to follow aftercare instructions. This release does not apply to claims arising from negligence, gross negligence, willful misconduct, or any conduct for which liability cannot be waived under applicable law.
Photography (Optional)
I authorize photographs to be taken for educational or marketing purposes.
I do not authorize photographs.
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HIPAA / Privacy Acknowledgment
All personal health information collected during your consultation will be kept confidential and used solely to provide safe and appropriate esthetic services, except as required by law.
Client Signature
I certify that I have read, understood, and completed this form truthfully. I have had the opportunity to ask questions and consent to the treatment(s) provided to me.
Client Signature:
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Date:
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Día
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Fecha
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We kindly ask that you respect our scheduling policies. Credit Card on File: A valid credit or debit card is required to reserve all appointments. By providing your payment information, you authorize JHL SPA, LLC to securely retain your card on file for the purposes outlined in this policy. Your payment information will be stored securely and will not be charged unless authorized under the terms of this agreement. Cancellation & Rescheduling: If you need to cancel or reschedule your appointment, we respectfully request that you provide at least 24hours' notice prior to your scheduled appointment time. Appointments canceled or rescheduled with less than 24 hours' notice, as well as missed appointments("no-shows"), will be subject to a cancellation fee equal to 50% of the scheduled service(s). This fee will be charged to the card on file. Late Arrivals: Clients arriving late may receive a shortened service to avoid delaying subsequent appointments. If there is insufficient time remaining to safely complete the service, the appointment may be considered a late cancellation or no-show, and the cancellation fee may apply. Exceptions: Cancellation fees may be waived at the sole discretion of JHL SPA, LLC in cases of verified emergencies or other unforeseen circumstances. Acknowledgment & Authorization: By signing below, I acknowledge that I have read, understand, and agree to the Appointment Cancellation &No-Show Policy. I authorize JHL SPA, LLC to charge the card I have provided for applicable cancellation or no-show fees in accordance with this policy
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First Name
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Signature
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