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New Client Intake Form

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth
MM slash DD slash YYYY
Occupation
Referred by
Email
How frequently do you receive skin care treatments? When was your last treatment?
What kind of skin care treatments have you received? Include approximate dates.
What is your current skin care routine for morning and night? Please be as descriptive as possible including product brand names and strength of prescription products.
What do you hope to achieve from your scheduled treatment? Have you taken steps to achieve this goal in the past?
Do you have any known allergies or injuries?*
Are you currently under the care of a dermatologist or a physician? If yes, please list reasons:*
Informed Consent and Treatment Policies*
I agree to the informed consent and treatment policies.
I understand the treatment I am receiving is for the purpose of relaxation and increased skin health. I understand a licensed esthetician does not diagnose illness or disease and the treatment I am about to receive is not a substitute for medical treatment or diagnoses.

I acknowledge the information I have provided on this form is correct and current to the best of my knowledge. It is my responsibility to inform my skin care therapist of any changes to this information. If I experience any unusual discomfort and/or pain during my treatment it is my responsibility to inform my skin care therapist so they can make the necessary adjustments.

I agree to sign a COVID-19 waiver for in person treatments until no longer deemed necessary.

I understand home care products may be recommended either in person or virtually and there may be side effects or risks associated with these recommendations. I accept responsibility for following any recommendations provided to me, either in person or via a virtual consultation.
Have you received a COVID-19 vaccine?*
- Yes
- No
Which vaccine did you receive?*
- Pfizer
- Moderna
- Johnson & Johnson
Date of vaccination*
Month
Day
Year
Consent*
I agree to the COVID test policy.*
If you have not been vaccinated for COVID-19, you must have a negative COVID test 24 hours before your appointment.
Cancellation Policy*
I agree to the cancellation policy.
Please call or use the online system to re-schedule or cancel your session at least 24 hours before the start of your appointment.
Late cancellations and missed appointments will be charged the full price of the session.
Late arrivals will be given the remainder of the scheduled treatment time.
If you are symptomatic due to COVID-19, please call the studio directly.
Phone
This field is for validation purposes and should be left unchanged.

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