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Client Skincare Intake Form

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Emergency Contact*
Who referred you?
How may we contact you? Select all that apply.*
Are you under a Physician's care? If yes, please describe below.*
Do you wear contact lenses?*
Are you pregnant or trying to become pregnant?*
Do you have skin sensitivities? If yes, please describe below.*
Have you had skin cancer?
Do you have any metal in your body? If yes, please specify below.*
Are you currently using or have you ever used any prescription acne medications or anti-aging creams? If yes, please describe below.*
Are you affected by any of the following? Check all that apply.
Which home products would you like more information on? Check all that apply.
What is your current home skin care regimen, AM & PM?
I understand the information here is to aid the skin care therapist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.*
I understand that Angelique Swann Esthetics & Wellness Solutions and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of Angelique Swann Esthetics & Wellness Solutions at my own risk, and to not hold Angelique Swann Esthetics & Wellness Solutions or staff liable for loss, damage or injury.*
I understand that results are personable and not guaranteed.*
I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that maybe relevant to my treatment at Angelique Swann Esthetics & Wellness Solutions.*
I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.*
I understand Angelique Swann Esthetics & Wellness Solutions has a strict 24-Hour cancellation policy. In the event of a late cancellation/no show the fee is the cost of your appointment or $50.00, whichever is less. An invoice will be sent, which is due upon receipt. If we are able to replace appointment with a client on wait list, we are happy to waive fee.*
I understand there are risks associated with skincare and waxing treatments. Such as: redness, sensitivity, peeling, inflammation. Any additional concerns I will discuss with my practitioner.*
Yes! I would love to be added to Angelique Swann Skincare & Beauty Solutions monthly newsletter for relevant information, timely topics, and special savings offers to enhance your life.
Signature (your name submitted below will be considered your electronic signature)*
Date Signed*