Client Intake & Consent Form
Provide your details and review your consent before submitting.
Welcome to Dessthetics! Your comfort, safety, and skin health are important to me. Please complete this form honestly before your appointment. Your responses will help me customize your service and identify anything that may affect treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What service are you receiving?
Facial
Brazilian Wax
Underarm Wax
Other
SKIN & HEALTH HISTORY
NOTE: Certain medications, products, conditions, or recent treatments may require your service to be modified or postponed.
Do you currently or have a history of the following?
Psoriasis
Sensitive skin
Rosacea
Dermatitis
PCOS or hormonal concerns
Diabetes
Cold sores/ herpes simplex
Eczema
Hyperpigmentation
Acne
None of the above
Are you currently pregnant or breastfeeding?
Yes
No
Do you currently have any implanted medical devices, electronic devices, or metal implants? Examples: pacemaker, implanted defibrillator, cochlear implant, insulin pump, metal plates/pins/screws, or other implanted devices.
Yes
No
Do you have any known allergies or sensitivities?
Yes
No
If yes: Please list allergies/sensitivities
Are you currently taking any prescriptions or over-the-counter medications that may affect your skin or healing?
Yes
No
If yes: Please list them.
Are you currently using any of the following ?
Retin-A / tretinoin
Retinol
Adapalene/Differin
Prescription acne medication
Antibiotics
Alpha hydroxy acids (AHAs)
Beta hydroxy acids (BHAs)
Benzoyl peroxide
Accutane currently or recently
None
Have you recently received any of the following?
Chemical peel
Micro needling
Laser treatment
Waxing
Microdermabrasion
Injectable/cosmetic procedure in the treatment area
Other professional skin treatment
None
Do you currently have sunburn, open wounds, cuts, sores, active rash, infection, severe irritation, or another concern In the area being treated?
Yes
No
If yes: Please explain.
Have you been professionally waxed before?
Yes
No
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FACIAL/SKIN CARE CONSULTATION
What are your primary skincare concerns?
Acne/breakouts
Dryness/dehydration
Oiliness
Dark spots/hyperpigmentation
Uneven skin tone
Texture
Fine lines/aging concerns
Sensitivity/redness
Dullness
Ingrown hairs
Maintenance/self-care
Other
How would you describe your skin?
Dry
Oily
Combination
Normal
Sensitive
Unsure
What products are you currently using at home?
Have you ever had a professional facial before?
Yes
No
Did you experience any reaction afterward?
Yes
No
FACIAL CONSENT
By submitting this form I understand that skin care treatments may involve cleansing, exfoliation, masks, extra extractions, massage, and or other techniques appropriate for the selected service. I understand temporary redness, sensitivity, dryness, irritation, or breakouts may occur following some skin care treatments. I have disclose relevant allergies, medication’s skin conditions, recent procedures, and products that could affect my service. I understand results very between individuals and no particular result has been guaranteed. I agreed to communicate immediately if I experience unusual discomfort during my service..
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WAXING CONSULTATION
Have you ever received a professional wax?
Yes
No
Have you ever experienced a reaction to waxing?
Yes
No
If yes: Please explain.
Have you shaved the treatment area recently? If so when?
Are you currently experiencing irritation, cuts, sores, sunburn or another skin issue in the area being waxed?
Yes
No
Do you have any other concerns or anything to share regarding the area being treated?
WAXING CONSENT
I understand that waxing removes hair from the follicle and may cause temporary, redness, tenderness, sensitivity, bumps, or irritation. I understand that possible complications can include skin, lifting, bruising, ingrown hairs, follicular, irritation, or other skin reactions. I have disclose medication’s skin care, products, and treatment treatments that could make my skin more sensitive to waxing. I understand that Dessthetics may modify postpone or decline a service when a contraindication or skin safety concern is present. By submitting this form, I agree to follow the recommended, waxing aftercare instructions and consent to all above.
AFTERCARE ACKNOWLEDGEMENT
I understand that aftercare is an important part of my service, and that failure to follow recommended aftercare may increase the likelihood of irritation or other wanted reactions. I understand that I should contact my aesthetician if I have any questions or concerns regarding my service or aftercare if I experience a serious or persistent medical reaction, I understand I should seek appropriate medical care.
FINAL CONSENT & SIGNATURE
I certify that the information I have provided on this form is true and complete to the best of my knowledge I understand that withholding relevant information about medication‘s health conditions, allergies, skin care, products, or recent procedures may affect the safety of my service. I have had the opportunity to ask questions regarding my selected service. I understand the nature of the service potential reactions and applicable aftercare instructions. I understand that individual results vary and no specific outcome has been guaranteed. I voluntarily consent to receiving the service(s) I have selected from DESSTHETICS.
Name
First Name
Last Name
Signature
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