Intake Form & Waiver for Services
Your answers are strictly confidential and will allow us to have a better understanding of your main concerns and goals to obtain a healthier skin.
Date of birth
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How did you hear about Essence of Beauty Skincare.
If you were referred by someone, please list their name
Street Address Line 2
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
E-mail that we will use to regularly communicate with you
Preferred Cellular phone number for voice and/or text communication
Besides the automatic emails and texts to confirm your appointments, how do you prefer we contact you regarding any questions or we may have?
Hair Removal Consultation
Are you exposed to the sun on a daily basis or are you considering to spend more time in the sun soon?
Have you used Accutane, Adapalene, Resorcinol, Differin in the last 12 months? If yes, waxing CANNOT be performed.
Are you currently using:
Retinol, Retin-A, Renova, Tretinoin, Vitamin A
AHA's (Alpha Hydroxyl Acids) Glycolic, Lactic, Mandelic
Scrubs or Peels
Allergic to latex?
Other known Allergies?
Menstrual cycle due date?
For your own personal comfort, allow at least three days before due and three days after finishing your menstrual cycle. However, waxing while on your cycle is not a problem at all and is sometimes necessary due to scheduling challenges. My Cancelation Policy applies even if your Moontime arrives.
I understand I may carry Hepes and/or MRSA (Staph Infection) without any physical symptom or have had a medical diagnosis confirmed.
I understand if I have Herpes and/or MRSA I may experience an outbreak.
Please note that Hair Removal may cause: Redness, swelling, tenderness, pimples, bruises, skin removal, scarring or hyperpigmentation.
I understand all of the above mentioned reactions. I also understand if I change my skincare routine or medications I must inform the professional PRIOR to starting any services in the future.
What are your main skin concerns at this time?
If you could wave a magic wand how would your skin look in one month?
Any special requests for today? (Extractions, skin soothing, skin clearing, hydration, relaxation, waxing)
What did you LOVE about your last facial and what could you have lived without?
Is there anything I need to know before we get started? The more I know, the better your results. (Please list: Allergies, Sensitivities, Pregnant, Nursing, Health issues, Diabetic, Medications, Metalplates, Cold sores, Herpes, Retin A use or any topical products that might cause skin sensitivities.
Knowing that home care is a big part of achieving beautiful and healthy skin, would you like to chat about how to maintain today's results at the end of your facial
Yes, give me the scoop on how to look and feel beautiful.
No, just here to relax.
Anything else you want to share? I love learning about my clients as it helps me provide superior customer service
a) Essence of Beauty Skincare, (Casandra Ocampo) and I (the client) will discuss and agree upon a treatment plan that will help me address my skincare concerns and achieve my skin care goals. I consent to the EOBSC team, licensed on the State of Texas, to perform face/body waxing, Micro-current, Microphototherapy, Rezenerate, ThermoClear, LED light Therapy, Electroporation, and/or physical/chemical exfoliation on me today and in the future. I will inform EOBSC immediately if my medical history changes.
b) I understand that while the goal of these treatments is to improve the vitality of the skin, no specific warranties of the results can or have been made. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.
c) I understand that it is imperative to my health that I disclose all of the information requested in the client intake form. I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. I understand conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
d) I acknowledge that I had not used Accutane, Differin, or ANY medication for the same purpose during the last 12 months.
e) I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment.
f) I acknowledge that it is no guarantee that discoloration of the skin will be reduced or fade. Pigmentation may improve or darken with successive treatments.I acknowledge the need for a proper, at-home professional skin care regimen for optimal success with anti-aging rejuvenation, acne, and hyperpigmentation.
g) I acknowledge if I fail to use a minimal sunscreen (SPF 30) every two hours while driving or outdoors, and an optional wide-brimmed hat, I am more susceptible to sunburn, skin damage and/or hyperpigmentation.
h) I acknowledge that my skin can experience temporary irritation, tightness, redness or slight swelling, which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that I should avoid the use of glycolic or retinol products for at least one week following the treatment in order to reduce any potential reaction.
i) I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes, knowing that my last name will be omitted and my eyes will be digitally blacked out to conceal my identity at my request.
j) I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that maybe relevant to my treatment at EOBSC
I understand that I must provide at least 24hours advance notice to reschedule or cancel an appointment.
Iunderstand Essence of Beauty Skincare has a strict 24 Hour cancellation policy. In the event of a late cancellation/no show the fee is $50.00. An invoice willbe sent via PayPal. If we are able to replace the appointment with a client on ourwaiting list, we are happy to waive the fee.
k) I have read, understand and agree to the appointments, packages and memberships cancellation polices clearly posted in Essence of Beauty Skincare website, online scheduling and onsite.
Please sign and date below
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Thanks for taking the time to complete this intake form and we
look forward to meeting you!
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