Intake / Consent Form Contact Info First Name (Required) Last Name (Required) Email (Required) Phone (Required) Address (Required) City State AZALAKASARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY 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 WaxingTweezingSugaringElectrolysisStringingDepilatoriesLaser Hair Removal Skin Treatments MicrodermabrasionChemical PeelsBotox / Collagen InjectionsDermaplaningResurfacing TreatmentsLaserOther When / Notes Products / Medications (Check Those That Apply) Acne medication (ie: Accutane)Retinoids/ Vitamin A Derivatives (ie: Retin A, Renova)Hormone / Nicotine PatchOther medications, supplements, herbal/homeopathic remedies, vitamins, diuretics, birth control / contraceptives or hormone therapies 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. 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. 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. (Required) Check here if you accept the agreement.