SKINCARE INTAKE AND CONSENT FORM

SKINCARE INTAKE & CONSENT FORM
Today’s Date:*

MonthDayYear
How Did You Hear About Us:*

Drive BySocial MediaWebsiteGoogle SearchCurrent Indigo ClientReferralOther
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
E-Mail:*
Emergency Contact Name & Number:*
For Emergency Use Only
Skin Type:*

NormalCombinationDryOilySensitiveI Don’t Know
Treatment Goals:*

ResultsRelax
Current Skin Concerns:*

Laxity & Loose Skin (Face or Body)Pigmentation (Face or Body)Wrinkles & Fine Lines (Face or Body)Congestion, Clogged Pores (Face or Body)Acne, Pimples (Face or Body)Scarring (Face or Body)Excess Hair (Face or Body)CellulitePockets of Fat/BulgesRednessDry or DehydratedExcessively OilyUneven Skin ToneLarge PoresBroken CapillariesDullnessTextural IrregularitiesOther
Current Skin Conditions:*

AcneCold SoresHivesRosaceaEczema (Atopic Dermatitis)PsoriasisKeratosis PilarisSkin Cancer (Melanoma, Basal, Squamous)Melasma (Pregnancy Mask)Chronic Ingrown HairsNoneOther
Are You Currently Using:*

Retin-A (Trentinoin, Tazarotene, Adapalene)Benzoyl PeroxideAccutaneAntihistaminesAntibioticsBlood ThinnersBirth ControlSupplements/VitaminsNoneOther
Do You Currently Have Or Are Being Treated For:*

CancerArthritisHormonal ImbalancesDiabetesHigh/Low Blood PressureHigh CholesterolCardiovascular Disease (CAD, CHF, PAD, heart attack, stroke, arrhythmia)Seizures or EpilepsyNeurological DisordersMigraineClaustrophobiaRecent Surgeries or InjuriesAuto-Immune Disorders (RA, lupus, IBD, MS)PCOS (Polycystic Ovarian Syndrome)Thyroid (hypo/hyper)Metal ImplantsPacemakerBlood-Borne Disease (HIV, hepatitis)NoneOther
Allergies or Sensitivities (Indigo is not responsible for unknown allergies):*
If Yes, Please Explain Above
Are You Pregnant Or Breastfeeding:*

YesNo
Do You Wax Your Face On A Regular Basis:*

YesNo
What Types Of Skincare Products Are You Using:*

CleanserTonerExfoliatorVitamin CRetinoidSerumsMoisturizerMasksOilsSPFNoneOther
CANCELLATION POLICY

If you need to cancel your appointment, please call at least 48 hours prior to your scheduled appointment. Failure to cancel your appointment within 48 hours or be present at the time of a scheduled appointment will be recorded in your profile as a "late cancellation" or “no-show.”
Late cancellations and no-shows may be charged 50% of the amount of the service missed.

CONSENT AGREEMENT

I affirm that I have stated all my known medical conditions and answered all questions honestly.
I agree to keep the skincare specialist updated as to any changes in my medical profile and understand that there shall be no liability to Indigo Salon and Day Spa should I fail to do so.

I understand that there shall be NO REFUNDS ON ANY TREATMENT.

*By SUBMITTING THIS FORM, you agree to the following:

1) Cancellation policy

2) Consent agreement

3) No refunds on any treatment
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SKINCARE INTAKE & CONSENT FORM