Client Intake/Consent Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Phone Number
Medical / History Data
Are you pregnant, breastfeeding, or nursing?
Are you currently taking any prescribed medications (such as antibiotics, blood thinners, acne medications/anything from a dermatologist, etc)? If yes, please list them below:
Do you have any known allergies/skin sensitivities? Please list:
Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any Vitamin A derivatives?
If so, how recent/ how often?
Have you recently received Botox/ Dermal Fillers?
Have you recently received a chemical peel or laser treatment?
Yes- in the last month
Yes-in the last 2-3 months
Did you undergo any major surgery in the past 90 days? If yes, please describe:
By submitting and signing this form, I acknowledge, and consent to the following:
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments.
I acknowledge that the esthetician holds the right to terminate the session at any time.
I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received.
I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.
I release the esthetician from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.
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