Studio Laluna Beauty

Studio Laluna Beauty Confidential Client Skin Health Intake Form

Client Information / Medical Information and Treatment Consent
PERSONAL INFORMATION
Name*

First NameLast Name
My current gender identity is:*
My sex assigned at birth is:*
Pronouns
Email*
example@example.com
Do you want to join our email list? (This ensures you are the first to hear about sales/deals, receive priority bookings, etc.)*

YesNo
Birthday*

MonthDayYear
Date
Mobile Number *

Area CodePhone Number
Emergency Contact*

Full NamePhone Number
Occupation*
How did you hear about us? (Facebook, Google, Instagram, etc.)*
Did anyone refer you to Studio Laluna Beauty? If so, please list them below.
Please check off any of the following that would apply to you:*

I have very minor/no skin concerns and I am interested in more relaxing, skin boosting treatments (spa facials, dermaplaning, etc.)I have some major skin concerns that I would like to address (acne, uneven skin tone/pigmentation, fine lines/wrinkles, scarring, ongoing redness/sensitivities, etc.)I am looking to work with someone virtually to address my skin concernsI am interested in microchanneling and microneedlingI am interested in the adult acne packagesI am interested in the anti-aging packagesI am interested in the skin soothing/anti-inflammatory packagesI am interested in the brightening packagesOther
Please check off any of the following that you are interested in:*

I am just looking to have this one treatment done.I am not interested in changing my skincare productsI am interested in starting a skincare routine that would be customized specifically for my skin and my skin goalsI have specific concerns that I would like to treat. I would like to be set up on treatment plan (custom skincare routine, in person treatments, educational handouts/resources)Other
CANCELLATION & LATE POLICY
Please respect our time. Your appointment is for your exclusive use. If you cancel or reschedule on short notice, it is extremely difficult or impossible to fill that appointment spot and often it goes unfilled.*24 hours notice is required for cancelling or rescheduling your appointment.* If you cancel or reschedule your appointment with less than 24 hours before your appointment time, your credit card will be billed for 50% of your appointment cost. If you cancel or reschedule your free consultation appointment with less than 24 hours before your appointment time, your credit card will be billed a $50 charge. If you no-show for your appointment, your credit card will be billed for 100% of your appointment cost. If you no-show for your free consultation appointment, your credit card will be billed a $100 charge. These charges are non-refundable. There is a range of reasons for cancelling an appointment. In order to be consistent with all clients, cancellation fees will only be waived in the event of a medical emergency requiring urgent professional treatment, a death in the family, or a natural disaster. If you are less than 15 minutes late, there is NO CHARGE, but please understand that due to time constraints, we may be unable to perform the full service or treatment. If you are 15 minutes late or more, your appointment will be considered a NO SHOW and your credit card will be charged the full 100% of the appointment cost. These charges are non-refundable.
Please sign to confirm your agreement to adhere to the guidelines*

Clear
MEDICAL/HEALTH RECORD
Do you have any medical conditions? If so, please list below:*
Please list any medications, supplements(vitamins, pre workout, protein powder), or herbal remedies you currently take:*
Please give a full list of allergies or sensitivities:*
Have you taken any of the following in the last 12 months?*

Antibiotics for AcneBirth controlDanazolAntidepressantsAccutane/RoaccutaneDifferinAntihistaminesCyclosporinDilantinSteroidsDisulfiramGanadotropinIVF TreatmentImuranTestosteroneIsonaziadLithiumRecreational DrugsRetin-AThyroid MedicationHormone TherapyN/A
Do you have any hormonal imbalances? Please detail if yes.*
Are you pregnant, breastfeeding, or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Do you have any Gynecological Conditions? Please detail if yes*
When was the first day of your last menstrual cycle? (if applicable)*
YOUR SKIN
What do you consider your skin type? (please select all that apply)*

NormalOilyAcneDryAgingCombinationSensitiveRosacea
Does your skin breakout?*

Almost alwaysFrequentlyRarelyNever
What are you skin concerns? (please select all that apply)*

BlackheadsScarringPermanent RednessDehydrated SkinBroken CapillariesSensitive SkinOily SkinItchy/Dry/Flaky SkinCystsFlushingPigmentationWhiteheadsAge SpotsDark SpotsLines/WrinklesPimples/Pustules
Any other skin concerns that aren't listed above? Please describe.*
When would you say these concerns began or when did you begin to notice them?*
What would you like to achieve with your skin?*
When you have an acne lesion or small wound, how long does it generally take to heal? Would you describe yourself as slow to heal?*
How do you feel your skin's hydration levels are?*
Do you use makeup wipes?*
Do you use any of the following (energy drinks, protein drinks, premier protein, fairlife drinks, creatine, BCAAs, protein powder, pre workout)?*
Please list all of products in your SKIN CARE morning and night time routine. Please be as specific as possible. (IMPORTANT TO INCLUDE BRAND NAME AND PRODUCT NAME :IE: Avoid saying "Cerave Cleanser" Please instead list which cleanser "Cerave Hydrating Cleanser". Do not list "mandelic serum" but also include the brand "Bion Mandelic 8%Serum")*
Are you under the care of a dermatologist, esthetician or other skin specialist? If yes, which ones and what have you discussed with them?*
Have you received any of the following? (Please select any that apply)*

Corrective PeelsGlycolic PeelsMicroneedlingLaser or IPLMicrodermabrasionDermaplaningRecent SurgerySkin Cancer Removal/TreatmentDermal Fillers or BotoxN/A
If you checked off any of the above, when was your last treatment? What area was treated? How long have you been receiving treatments?*
Please list any other current treatments you are receiving (i.e. - facial treatments,hair removal / waxing etc.)*
SKIN TYPE ASSESSMENT

Please check the option that most closely describes your features.
Eye Color*

Light Blue / Grey / Green (0)Blue / Grey / Green (1)Dark Blue (2)Brown (3)Dark Brown / Black (4)
Natural Hair Color*

Sandy Blonde / Red (0)Blonde (1)Dark Blonde / Light Brown(2)Dark Brown (3)Black (4)
Skin Color (non exposed areas)*

Reddish (0)Very Pale (1)Pale with yellow or beige undertones (2)Light Brown (3)Dark Brown (4)
Freckles (on non exposed areas)*

Many (0)Several (1)Few (2)Incidental / Sporadic (3)None (4)
Reaction to prolonged sun exposure*

Painful redness, blistering,peeling (0)Blistering followed by peeling (1)Burns sometimes followed by peeling (2)Rarely Burns (3)Never Burns (4)
To what degree does the color of your skin deepen and darken when in the sun (not a burn)*

Hardly or not at all (burn)(0)Light tan color (1)Reasonably darker (2)Darken very easily (3)Darken quick and easily without burning (4)
Does your skin color deepen / darken (not redden) within a few hours of being in the sun?*

Never (0)Seldom (1)Sometimes (2)Often (3)Always (4)
How does your face respond to sun exposure?*

Very sensitive (0)Sensitive (1)Normal (2)Resistant / not much change (3)Little to no change (4)
LIFESTYLE
Do you feel the changing seasons or weather impacts your skin? If so, how?*
How are your energy levels? Are the consistent or do you crash?*
What would you say your level of commitment to your skin is? (If you have a budget you would like me to keep in mind when recommending products, please note it below) Example - I'll do whatever it takes and like a well rounded regimen / I am low maintenance and on a budget so I want to do the bare minimum*
Please select all that apply to you:*

I smoke tobacco/marijuana/vapeI use a tanning boothI pick my skinI have difficulty sleepingI wear sunscreen dailyI use fabric softenerI wash my pillowcases weeklyI sanitize my phone oftenI let products run down my face in the showerI cleanse my face in the showerI use hot water when washing my faceI don't wash my face after sweatingI go to bed with wet hair sometimesI wear a hat regularlyI wear a mask regularlyI brush my teeth, then cleanse my faceMy partner/significant other has a beardI frequently clean my makeup brushesN/A
Rate your current stress levels:*

LowModerateHighVery High
Rate your daily water intake*

LowModerateHighVery High
Rate your weekly alcohol intake*

LowModerateHighVery High
Rate your weekly time spent outdoors*

LowModerateHighVery High
Rate your weekly time spent driving*

LowModerateHighVery High
Do you regularly eat any of the following: (check all that apply)*

Dairy ProductsPastaSushiSeaweedKelpFast FoodWhite BreadProcessed sugarsPeanuts or peanut butterN/A
What does your diet consist of? You may also list a typical day of eating for you with specific meals. (Please be as specific as possible, as what many deem as healthy isn't always great for acne or anti-aging.) Do you consume a lot of anything specific?*
If you currently see a hairdresser how often? What type of styles do you usually get done (i.e. weaves, braids, blow-outs, etc):*
Please list all the products you use for MAKEUP, HAIR PRODUCTS, BODY CARE AND LAUNDRY PRODUCTS. Please be as specific as possible. (IMPORTANT TO INCLUDE BRAND NAME AND PRODUCT NAME):*
LET'S CUSTOMIZE YOUR APPOINTMENT EXPERIENCE
What is the purpose of this appointment? (please select all that apply)*

Stress ReliefI want to learn about skincare options that would benefit my skinI want to learn about my skinRelaxationOther
How interactive would you like your appointment to be? (please choose one)*

I like to chit-chat throughout my entire appointmentI would like a silent appointmentI don't mind a little bit of talking during my appointment
Would you like "touch" included in your appointment?*

Touch (include facial massage, hand massage, other touch related to your specific treatment, etc.)No Touch
Please let us know any other information that would help make the experience as customized and personalized to you.*
PERMISSION TO USE IMAGES

I grant to Studio Laluna Beauty, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Studio Laluna Beauty along with its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Studio Laluna Beauty and affiliates may use such photographs of me with or without my name as stated in the below selection and for any lawful purpose, including for example such purposes as publicity, education, training, illustration, advertising, and Web content.
Image Release preference. Please select the option you are most comfortable with:*

Yes, but please conceal my identity when utilizing images. (Eyes will be covered in final image)No, I do not need my identity concealed when images are utilized.I understand my images will be taken & stored confidentially in order to track my progress, but I do NOT give permission for my images to be shared publicly.
By SUBMITTING THIS FORM, you agree that you have read and completely understood the following:
1) I give my permission to receive skin treatments and facial treatments.

2) I understand there can be risks associated with the service(s) I am to receive. I understand that these risks include allergies, sensitivities, or adverse reactions.

3)I understand the importance of informing my therapist of all medical
conditions and medications I am taking, and to let the therapist know
about any changes to these at any ongoing appointments. I understand that there may be additional risks based on my physical condition.

4)I have read and understood the contraindications to treatment and pre/post care information on the Studio Laluna Beauty website for the services I am receiving.

5)I understand and agree to follow the pre and post care instructions provided by my technician, and that failure to do so will result in undesirable outcomes that Studio Laluna Beauty is not responsible for.

6)I understand that no refunds for services or products will be issued at anytime, for any reason.

7)I understand that I may not be a candidate for the service I am about to receive for a variety of reasons, including but not limited to: body chemistry or improper aftercare, and that results and lasting outcomes may vary.

8)I release my technician from all liability associated with the procedure(s) I undergo at Studio Laluna Beauty. There are no guarantees for how long this service will last, as each individual case varies. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.

9)I understand that if an allergy, sensitivity, or adverse reaction occurs, I am to seek a health care practitioner. I understand that my technician is not a medical professional who is able to diagnose, treat, or work on anything except healthy conditions.

10)I have clearance from my Doctor where necessary to receive the treatment / therapy I am booking for.

11)I understand that it is my responsibility to inform my therapist of any
discomfort I may feel during the session so he/she may adjust the treatment
accordingly.

12)I understand this is a cosmetic procedure and payment is my responsibility. It is non-refundable.

13)Regarding treatments:Skin treatments and facial treatments are physical treatments used to remove superficial/dead layers of the skin. The intensity of the procedure can be adjusted to your desired results and comfort level. Exfoliation treatments can have many benefits for the skin, including: reduction of congestion and acne, reducing the appearance of scars, wrinkles, pigmentation, and other skin conditions. Products are better absorbed into the skin and makeup goes on smoother after treatment. A series of treatments is recommended for maximal results. I acknowledge that I have been informed that exfoliation treatments using a blade on the face DO NOT cause the hair to grow back thicker or darker. The structure of the vellous hair (thin, translucent hair) is not damaged during treatments and grows back the same. However, because the hair is cut, it grows back with a blunt edge but the hair has not been physiologically altered. Contraindications: Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for exfoliation treatments and must be disclosed prior to treatment. These include: Extremely oily skin, active acne, active cold sores present in treatment area, any raised lesions, recent chemical peels, chemo/radiation, eczema, dermatitis, history of hypertrophic scarring or keloid formation, blood thinner medications, severe rosacea, skin cancer, sunburn, thick/dark facial hair, Accutane use within the past year.

14)Regarding post care: I take every precaution to ensure that your skin is well hydrated and calm following each session. However, you may experience excessive dryness or even some peeling between sessions. Always contact me if you have any concerns. More sensitive skin may experience some redness, swelling, warmth, tightness after the first couple of sessions. This normally goes away after 2 to 3 hours. With extremely sensitive skin, there is a small risk of streaking with this procedure. This should subside 2-3 days after treatment. Your fresh, newly exposed skin will be delicate. It is important that you use a gentle cleanser and keep the skin well moisturized particularly around the delicate eye area. I understand a sunblock of at least SPF 30 is strongly encouraged to use daily. Swimming and tanning beds should be avoided for 1 week. I agree to avoid the use of Retinol, Retin-A, Renova, alpha or beta hydroxyl acid(AHA or BHA) products and all forms of scrubs for at least 24 hours after a treatment. We recommend using clean fingers and hands to apply product to your face. Please avoid applying makeup for 24 hours after your treatment. After that time, we recommend thoroughly washing brushes before using them on your face.

The information I have provided Studio Laluna Beauty is for my benefit and safety. I hereby consent to receiving exfoliation services from Studio Laluna Beauty. I hereby waive any and all claims or rights on my behalf as a result of any service rendered and release and forever discharge Studio Laluna Beauty from any and all claims and responsibility or cause of action arising from the rendering of exfoliation treatments. To my knowledge, I have no medical conditions or allergy that would preclude me from having this procedure done. I agree to hold Studio Laluna Beauty harmless of any and all medical complications that may arise. I have been advised to discontinue use and consult a physician if any reaction occurs. I agree to hold Studio Laluna Beauty harmless of any and all damage or loss of personal items. I agree that I have read and fully understood this consent form.

This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Studio Laluna Beauty. I understand that this agreement is binding and that I have read and fully understood all the information above.
TERMS AND CONDITIONS
By selecting the box below, you are agreeing to the terms and conditions above.*

I agree to the terms and conditions.
Signature*

Clear
Should be Empty:

Studio Laluna Beauty Confidential Client Skin Health Intake Form

PERSONAL INFORMATION

CANCELLATION & LATE POLICY

MEDICAL/HEALTH RECORD

YOUR SKIN

SKIN TYPE ASSESSMENT

LIFESTYLE

LET'S CUSTOMIZE YOUR APPOINTMENT EXPERIENCE

PERMISSION TO USE IMAGES

TERMS AND CONDITIONS