Client Intake Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Skin Care

1. Would you classify your skin type as sensitive, acne prone or normal (no sensitivities)? *

2. What would you like to achieve from your treatment(s)? *

3. Have you ever had a facial treatment before? *

Please give details (including when): *

Fitzpatrick skin types:
1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

4. Which of the above skin types would you say is closest to your skin? *

5. Which of the following best describes your skin type? *

6. Do you have any special skin problems or concerns pertaining to your face or body? *

Please give details: *

7. Have you ever had chemical peels, laser or microdermabrasion? *

Please give details (including when): *

8. Have you ever used Retin-A, Renova, Adapalene Hydroxyl Acid (AHA) or Retinol/vitamin A derivative products? *

Please give details (including when you last used these): *

9. Have you ever had any acne medication(s)? *

Please give details (including when you last used these): *

10. What skin care products are you currently using? *

(Please list brand, product type and any description - you can also send a photo of what you currently use)

11. Have you used any of the following hair removal methods in the past 6 weeks?

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories

12. What areas of concern do you have regarding your skin? Please check all that apply: *

If Other, please specify:

13. Have you ever experienced any skin sensitivities to any skincare products, ingredients, cosmetics, food products (citrus, berries etc.), medicine, fragrances, sunscreens, latex etc.? *

Please specify: *

14. Do you wear SPF daily? *

15. Have you ever had Botox, Restylane or Collagen injections? *

Please specify (including when): *

Are you currently pregnant, or trying to become pregnant? *

Are you nursing? *

Any menopause problems? *

ANY ADDITIONAL NOTES/COMMENTS:

Consent

I understand, have read and completed this intake form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from any treatments received. The treatments I receive here are voluntary and I release AESTHETICSBYTINA LLC from liability and assume full responsibility thereof.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign

Photo and Video Consent

I, hereby grant and authorize TINA MCCONNELL (Aestheticsbytina LLC) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now known or later discovered.

I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

I hereby hold harmless and release TINA MCCONNELL (Aestheticsbytina LLC) from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

Permissions granted for the pictures, video, and/or audio listed below:

Picture/Video/Audio Description: Before photos/videos, during the service photos/videos and after photos/videos

Date taken: Date the service is performed

Do you consent to any photos or videos taken before, during and after your services? *

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign