2021 Confidential Client Intake Form

Have you used Retin-A, Renova, AHAs or Retinal/Vitamin A products in the last three months?*

YesNo
If yes, please explain
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*

YesNo
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that

would make the requested treatment unsuitable. I will inform the technician of any discomfortI

may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
By signing below, I agree to all terms*

I agree to use electronic records and signatures.
Today's Date*

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Signature*

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General Information