Intake / Consent Form

Contact Info
First Name (Required)
Last Name (Required)
Email (Required)
Phone (Required)
Address (Required)
City
Zip
Emergency Contact
First Name (Required)
Last Name (Required)
Relationship (Required)
Phone (Required)
Pregnancy Info
Are You Pregnant (Required) YesNo
How many weeks
Due Date
Care Provider
Are You High Risk YesNo
Explain
Did you recently give birth (Required) YesNo
Are you lactating / breastfeeding (Required) YesNo
General Info
Have you ever had a facial treatment (Required) YesNo
When and what type
Do you have sensitive skin (Required) YesNo
Explain
Do you have any allergies / sensitivities (Required) YesNo
Explain
Have you ever had a reaction to a cosmetic product (Required) YesNo
Which products
Are there any scents or oils that bother you (Required) YesNo
Explain
Have you recently been sun burned or been in a tanning bed (Required) YesNo
When
Recent Treatments (Check Those That Apply)

Hair Removal

Skin Treatments
When / Notes
Products / Medications (Check Those That Apply)
How Often / Notes
Other
Is there any other necessary information your Esthetician should know before beginning your treatment?
Explain / Notes
Consent
Click here to view the agreement.

(Required) Check here if you accept the agreement.