• Welcome & Client Registration

  • CLIENT COMPLETES • First appointment

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Please provide accurate information. Your esthetician may request updated information before future services.
  • ROOTED SKIN & ESTHETICS | LA VERNIA, TEXAS
  • 01
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  • Health & Safety Intake

  • CLIENT COMPLETES • Update whenever your health or medications change
  • Pregnant or breastfeeding*
  • Current or previous isotretinoin use*
  • Retinoids, acids, exfoliants used recently*
  • Recent sunburn, tanning, or significant sun exposure*
  • Recent peels, lasers, injections, or skin procedures*
  • Active rash, infection, cold sores, or open skin*
  • ROOTED SKIN & ESTHETICS | LA VERNIA, TEXAS
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  • Skin History & Goals

  • CLIENT COMPLETES • Consultation

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  • 03
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  • General Facial Informed Consent

  • CLIENT COMPLETES • Before receiving treatment
  • I understand facial treatments may include cleansing, massage, exfoliation, masks, extractions and topical products as appropriate. Possible temporary effects include redness, dryness, sensitivity, irritation, breakouts or allergic reaction. Results vary and cannot be guaranteed. I may ask questions, decline any step, or stop the treatment at any time.

    I agree to disclose relevant health information, allergies, medications, recent procedures and changes in my skin. I understand the esthetician may modify or decline a treatment for safety reasons. This service is cosmetic and is not medical diagnosis or treatment.
  • Date (MM/DD/YYYY)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • ROOTED SKIN & ESTHETICS | LA VERNIA, TEXAS
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  • Advanced Treatment Consent

  • CLIENT COMPLETES • Only for services actually performed
  • Check each service discussed with your esthetician. Specific risks, expected recovery, contraindications and alternatives should be reviewed before treatment. This form does not replace device-specific or peel-specific manufacturer instructions.
  • Services discussed
  • Date (MM/DD/YYYY)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • ROOTED SKIN & ESTHETICS | LA VERNIA, TEXAS
  • 06

  • Photography & Communication

  • CLIENT COMPLETES • Optional permissions

  • Treatment is not conditional on agreeing to promotional photos or marketing. Choose each permission independently. Consent can be withdrawn for future use by contacting Rooted; prior lawful publications may not be fully retractable.
  • Clinical progress photos stored privately in my client record*
  • Use identifiable photos/videos on Rooted social media or advertising*
  • Publish my testimonial with my first name*
  • Send appointment-related text or email reminders*
  • Send optional promotional emails or texts*
  • Date (MM/DD/YYYY)*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Client Service Policies

  • CLIENT COMPLETES • Adapt to Rooted's published policies

  • Appointments: Please arrive on time. Late arrival may shorten a service. Cancellation and no-show fees, deposits, refunds and package expiration terms must be clearly provided at booking; do not apply unpublished fees.

    Safety: Treatment may be postponed when contraindications, active skin conditions or other concerns make the planned service inappropriate. Client information is stored with access restricted to authorized personnel.

  • Date (MM/DD/YYYY)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • BUSINESS CONTACT • 720-854-4971 • estibestie26@icloud.com
  • ROOTED SKIN & ESTHETICS | LA VERNIA, TEXAS
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