New Client Intake Form

First name

Last name

Phone

Birthday

Month

Day

Year

How did you hear about us?

Client Referral

Google Search

Facebook/Instagram

Other

If referral or other, please give details

Have you ever received treatments from an esthetician?

Yes

Have you been under the care of a dermatologist in the last 12 months?

Yes

List any medications or supplements you are currently taking.

Are you using any topical medication or exfoliating acids like salicylic or glycolic? (if yes, please explain)

Have you ever had an adverse reaction to a cosmetic product? (if yes, please explain)

What are you currently using to cleanse and moisturize your face?

Do you currently use any special treatments? (eye , scrubs, masks, etc.)

How many glasses/cups of water do you drink daily?

Do you wear contact lenses?

Yes

Are you bothered by scents, oils or lotions? If yes, explain

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or any Vitamin A/Retinol derivative?

Yes

Have you used any of the above in the last 3 months?

Yes

Have you ever used an acne medication? If yes, when and which one?

Have you ever had an allergic reaction to food, sunscreens, or AHAs? Yes / No If yes, please explain:

Cancellation Policy Acknowledgement

To provide the best care and respect everyone's time, please review and acknowledge the following cancellation policy:

I understand that 24 hours notice is required to cancel or reschedule any appointment.
I acknowledge that no-shows or cancellations made within 24 hours of the scheduled appointment will result in a 100% charge of the service booked.
I understand that arriving more than 15 minutes late may result in my appointment being rescheduled and a late fee applied.
I acknowledge that last-minute cancellations not only affect my appointment, but also the provider and other clients who may have needed that time.

I have read and understand the cancellation policy above, and I agree to abide by its terms.

Skin Care Consent

I certify that the above information is correct to the best of my knowledge. In accordance with the law, Normal Skin cannot cure, treat, prevent or diagnose any condition. These treatments are used as regimens for improving skin appearance and wellness. Information exchanged during any session should be given at my own discretion.

Because certain esthetics treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the skin care therapist updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the therapist’s part nor on the part of Ethos of Annapolis and its affiliates should I fail to do so.

The therapist reserves the right to refuse service to anyone for any reason.

I fully understand that the therapist performs her services within the parameters of esthetics, using skin care treatments and therapies. I fully understand that the esthetics therapist is not an allopathic doctor, dermatologist, or psychiatrist and does not portray himself/herself to be.

If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the products and/or techniques may be adjusted to my level of comfort.

By signing 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 regard to any services or therapies offered. All client information is confidential.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.