Facial intake/ consent form Name * First Name Last Name Pronouns Email * Phone * (###) ### #### Have you ever had a facial? * Yes No Do you have sensitive skin? * Yes No Please include any topical allergies or reactions you've had in the past: Are you pregnant? Disregard if it doesn't apply Yes No If yes, how many weeks? Are you breast or chest feeding? Disregard if it doesn't apply Yes No Do any scents or oils bother you? Have you recently used a tanning bed or been sunburned? * Yes, tanning bed Yes, sun burn No Select all hair or skin treatments you've received recently: * Wax/ sugaring/ brow lamination/ threading Dermaplaning Injections Chemical peel Microdermabrasion Microblading Lash extensions/ lash perm None of the above If you checked any of the above treatments, please say how long ago / how often? Do you use any of the following: * Hormonal birth control Herbal remedies / supplements Regular medications None of the above If you checked any, do you notice them affecting your skin? Emergency Contact * First Name Last Name Relationship Emergency Contact's Phone (###) ### #### Consent Agreement * I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that Esthetics/ Skin care therapy cannot cure, treat, prevent or diagnose conditions. These treatments are used as regimens for improving skin appearance and wellness. I furthermore understand that Esthetics should not be considered a substitute for medical examination and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. Any information exchanged during a skin treatment session is confidential, should be given at my own discretion and is only used to provide the best skin care treatment. If I experience any pain, discomfort or experience any complications I will discuss them with my Esthetician immediately so that the products and/ or techniques may be adjusted to my level of comfort. I understand that withholding any information or providing misinformation may result in contraindications and/ or irritations of the skin from treatments received. I understand that everyone's skin is different and irritations may occur. The Esthetician reserves the right to refuse service to anyone for any reason. I understand that there is a $30 same day cancellation fee and as a courtesy I will allow 48 hours for appointment changes or cancellations. I understand that the proper client care requires the full amount of time allotted for visits, and that if I arrive more than 10 minutes I may need to reschedule or pay the $30 same day cancellation fee. By checking the box below I acknowledge that I have read and understand all parts of this consent/ intake form and that I have had the opportunity to ask any questions with regards to any services offered. I release Touch of Radiance, LLC. and any of its Estheticians from any liability. Click here if you accept the agreement How did you hear about us? Thank you!