Client Intake/Consent Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Medical / History Data
Are you pregnant, breastfeeding, or nursing?
Yes
No
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?
Yes
No
If so, how recent/ how often?
Have you recently received Botox/ Dermal Fillers?
Yes
No
Have you recently received a chemical peel or laser treatment?
No
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:
Authorization
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.
Date
-
Month
-
Day
Year
Date
Signature
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