SKINCARE INTAKE AND CONSENT FORM

SKINCARE INTAKE & CONSENT FORM
Today’s Date: *

Month Day Year
How Did You Hear About Us: *

Drive By Social Media Website Google Search Current Indigo Client Referral Other
Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Address: *

Street Address

Street Address Line 2

City State / Province

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

Normal Combination Dry Oily Sensitive I Don’t Know
Treatment Goals: *

Results Relax
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) Cellulite Pockets of Fat/Bulges Redness Dry or Dehydrated Excessively Oily Uneven Skin Tone Large Pores Broken Capillaries Dullness Textural Irregularities Other
Current Skin Conditions: *

Acne Cold Sores Hives Rosacea Eczema (Atopic Dermatitis) Psoriasis Keratosis Pilaris Skin Cancer (Melanoma, Basal, Squamous) Melasma (Pregnancy Mask) Chronic Ingrown Hairs None Other
Are You Currently Using: *

Retin-A (Trentinoin, Tazarotene, Adapalene) Benzoyl Peroxide Accutane Antihistamines Antibiotics Blood Thinners Birth Control Supplements/Vitamins None Other
Do You Currently Have Or Are Being Treated For: *

Cancer Arthritis Hormonal Imbalances Diabetes High/Low Blood Pressure High Cholesterol Cardiovascular Disease (CAD, CHF, PAD, heart attack, stroke, arrhythmia) Seizures or Epilepsy Neurological Disorders Migraine Claustrophobia Recent Surgeries or Injuries Auto-Immune Disorders (RA, lupus, IBD, MS) PCOS (Polycystic Ovarian Syndrome) Thyroid (hypo/hyper) Metal Implants Pacemaker Blood-Borne Disease (HIV, hepatitis) None Other
Allergies or Sensitivities: *
If Yes, Please Explain Above
Are You Pregnant Or Breastfeeding: *

Yes No
Do You Wax Your Face On A Regular Basis: *

Yes No
What Types Of Skincare Products Are You Using: *

Cleanser Toner Exfoliator Vitamin C Retinoid Serums Moisturizer Masks Oils SPF None Other
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 will 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
Signature: *

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SKINCARE INTAKE & CONSENT FORM