INTAKE FORM | SIGNATURE FACIALS

ALL INFORMATION IS CONFIDENTIAL.

Name (required)

Date (required)

Address (required)

Email (required)

Cell Phone (required)

Whom may we thank for your referral?

Which concerns apply to your skin? (required)

Other concerns:

What skincare products do you use?

List the name brands of your skincare products:

Please check the prescription medications you are currently using:

Other:

Are you allergic to any cosmetic ingredient, medication or food? Please list:

In the past 30 days, please list all professional facial or dermatology services you have received (i.e. Chemical Peel, Microdermabrasion, Laser, Botox, etc. (required)

Please take a moment to carefully read the following list of conditions and check any that have affected your health either recently or in the past: (required)

If yes, please include additional information:

I confirm that all information provided is true and accurate to the best of my knowledge. I accept full responsibility for informing my esthetician of any physical or mental condition that may affect my treatment or results. I understand that my service is therapeutic in nature and agree to notify my esthetician immediately of any discomfort during my treatment. (required)

I understand and acknowledge there are risks involved with the treatment of facials, peels, microdermabrasion, microcurrent, electrical skin treatments, and waxing. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive the Esthetician's liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications, or effects and hereby waive the Esthetician's liability if such results or complications occur. In consideration for the Esthetician performing this procedure, I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I amundergoing this procedure or side effects I may experience after the procedure is performed. I understand that the Esthetician does not diagnose illness, disease, or any other physical or mental conditions. Any sexual misconduct exhibited by the Client will result inimmediate termination of the session, and the client will be liable for payment of the scheduled appointment. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against the Esthetician, service providers, owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. I agree this waiver and release shall bind themembers of my family and any spouse or domestic partner, if I am alive, aswell as my estate, family, heirs, administrators, personal representatives or assigns it 1 am deceased, and shall be deemed as a "Release, Waiver, Discharge and Covenant" not to sue the Esthetician or any of the service providers. (required)