Service Consent Form

Service Consent Form

Please complete this form at least 24 hours before appointment. A completed form is required on file to receive services.
If a completed form is on file from a previous appointment, please skip filling it out this time! If there have been significant changes to your health or skin concerns, you may complete it again.
Today's Date*

MonthDayYear
Date
Date of Birth *

MonthDayYear
Date
Client Name*

First NameLast Name
Phone Number*
Email*
example@example.com
How did you hear about Kylie Anne Esthetics?*

Facebook/InstagramOnline SearchReferralOther
If referred, by who?
Your Medical History
Are you currently under the care of a Physician / Dermatologist?*

YesNo
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancerHigh Blood PressureDiabetesHeart ProblemsArthritisAuto-Immune DisorderAsthmaEpliepsy/SeizuresCold SoresHIV/AIDSLupusDepression/AnxietyHeadaches/MigranesNoneOther
Please explain here if you answered "Other" for the above question:
Please list any known allergies:*
Please list medications/supplements you are currently taking:*
This includes topical products like prescription Tretinoin.
Have you ever received botox or fillers? If so, where and when? *
Please note: it is strongly recommended to wait a full 2 weeks (14 days) post-botox or filler to schedule a facial appointment
Your Skin
What are your top 2-3 skin concerns?*
What skincare products do you use on a daily or weekly basis?

CleanserTonerSerum(s)Face MaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinoid)
Do you experience routine breakouts or consistent acne?*

YesNo
Have you ever been diagnosed with eczema, psoriasis, rosacea, or any other skin condition?*

YesNo
Have you received any of these facial hair removal services in the last 7 days?*

Waxing/SugaringThreadingLaser/ElectrolysisNone
Are you currently on any prescription medications for your skin specifically (orally or topically):*

YesNo
Please specify which product(s) if you answered YES to the above question.
IF YOU ARE CURRENTLY TAKING ACCUTANE YOU MAY NOT RECEIVE FACIAL OR WAXING SERVICES
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinoids)Exfoliating scrubsUnsureNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within the last monthYes, within the last 2-3 monthsNo
Do you:*

Wear contact lensesHave a pacemakerHave metal implantsSmoke/VapeFrequent tanning bedsWorkout frequentlyPick at your skinNone
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or breast-feeding?

YesNo
Photo/Video Consent
I consent that Kylie Anne Esthetics LLC may take and use my photographs/videos/digital content on social media platforms (like but not limited to Instagram, Facebook, business website, Google, etc.).*

YesNo
I acknowledge that cancellations must be completed at least 24 hours ahead of scheduled appointment time. Failure to do so will result in the card on file being charged 50% of the scheduled service cost.

I acknowledge that a no-show will result in the card on file being charged 100% of the scheduled service cost. I understand that if I am 10 or more minutes late to my appointment, the no-show policy will be applied.

I acknowledge that Kylie Anne Esthetics LLC requires a card on file at time of booking for the purpose of the above cancellation and no-show policy enforcement.
I acknowledge that my skin may experience temporary irritation, tightness, redness, peeling, and/or flaking, which usually dissipates within 72 hours depending on my skin and the treatment provided.

I acknowledge that if I have an active cold sore I cannot make an appointment until it has run its course (approximately 2 weeks). If an active cold sore appears between the time I book my appointment and the appointment date, I will reschedule (with no fee) for a date at least 2 weeks later.

I acknowledge that it is recommended to discontinue use of exfoliants and retinoids 5-7 days before my scheduled appointment.

I acknowledge that Kylie Anne Esthetics LLC has the right to refuse any service that, in their professional opinion, should not be performed at time of appointment.

I acknowledge that Kylie Anne Esthetics LLC and its staff have the right to alter the services that I have booked if it means upholding the integrity of my skin (i.e. removing a dermaplane service for a client who is at that time not a candidate for that service).

I acknowledge that I will receive aftercare recommendations/instructions post-treatment and if I do not follow those recommendations, I do not hold Kylie Anne Esthetics LLC liable.

I consent, to the best of my knowledge, that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. By signing this form, I give consent for all future treatments performed by Kylie Anne Esthetics LLC and its staff.

I release Kylie Anne Esthetics LLC and its staff of any liability associated with any injuries and/or current and future conditions resulting from skincare procedures or products.
Signature

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Contact Kylie Anne Esthetics at 980-318-1980 or the "Contact" page of the website. Please note that responses will occur during business hours only.
Should be Empty:

Service Consent Form

Your Medical History

Your Skin

Female Clients

Photo/Video Consent