New Client Form

New Client Form
Date*

MonthDayYear
First Name *
Last Name*
How did you find me?*
Date of birth*
Address*

Street Address

Apt

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Zip Code
Cell #*
Best Email to Reach You*
For post-facial instructions, confirmations, receipts, and other important notifications.
How may I contact you for specials and helpful information?

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Lateness, Cancellation, Service Changes and Rescheduling Policy

The time you book is reserved just for you! Accommodating late guests is often impossible without disrupting every other guest's schedule, and I want Calm to remain a relaxing environment for you with unhurried service.

If you are more than 10 minutes late, please keep in mind that I'll need to -

a. shorten the service so we finish on time, and you will be responsible for full payment of the service(s) booked.

b. or reschedule your appointment and charge a cancellation fee equal to 50% of the amount of the services booked.

If you wish to change services booked, cancel or reschedule your services booked, please provide at least 48 hours notice to avoid being charged a fee equal to 50% of the amount of the services booked. No-shows will be charged the full amount of the services booked. By giving inadequate notice or no notice at all, you prevent someone else from being able to schedule that time slot.

Initial in the box below if you agree to this policy and wish to continue with your scheduled appointment.
Please Initial here*
Why are you visiting me? Check all that apply.

acne (face)back acneacne scarseye bagsdark circles (eyes)wrinklesneck/jawline sagdecolletefacial hair removalpoor texturerosacearednessdark spotspore cleaningdrynessexcessive oilinesslarge poressun damagebroken capillariestension in head, TMJ, neckOther
Assessing risk and your ability to benefit from skin therapies

All skin therapies carry risks and possible side effects (explained below). The following skin therapies may be used to achieve the results you desire. There are certain circumstances in which I cannot use these or have to alter how they are used. These are known as contraindications. Questions below the descriptions of skin therapies are used to assess your contraindications, which is vital to ensure your safety and wellbeing before, during and after your treatment.
Advanced Exfoliation Methods:

Chemical Peels: Professional chemical peels use substances such as glycolic, salicylic, pyruvic, mandelic, malic, glycolactone or lactic acid to rejuvenate skin, decrease acne, minimize the look of fine lines, wrinkles, sun damage, acne scars or hyperpigmentation, depending on which peel is used.

Spicules or Liquid Microneedles: Spicules, also known as liquid microneedles, use substances such as hydrolyzed or marine sponge, coral calcium, crystallized hyaluronic acid spears, to penetrate the skin surface to rejuvenate skin, minimize the look of fine lines, wrinkles, sun damage, acne scars or hyperpigmentation. Spicules can feel prickly upon application and for up to 72 hours after.

Dermaplaning: Dermaplaning is the use of a disposable surgical blade to exfoliate the skin and remove fine vellus hair (peach fuzz). It can minimize the appearance of surface hyperpigmentation, acne scars, fine lines and wrinkles. It may be combined with an enzyme or peel to help with penetration of nutrients. The hair that grows back after Dermaplaning will not be darker or thicker; however, any hormonal imbalance that may be present within your anatomical system can alter the normal hair growth pattern.

Hydro-dermabrasion: Exfoliates using alpha hydroxy and salicylic peels delivered through a handpiece that moves over the skin, extracts whiteheads and blackheads via adjustable suction.

Microdermabrasion: exfoliation of skin using organic flower matter or metal tip.

ReZenerate or Revitapen or Nano-Pen: exfoliation of skin using a silicone chip or metal head that infuses serums.

Possible Reactions and Complications for Advanced Exfoliation:

During an Advanced Exfoliation, you may experience discomfort, warmth, redness, tingling, itchiness; spicules in particular, feel prickly. Most of these sensations will dissipate within a few hours. Spicules, however, can feel prickly for up to 72 hours as they keep working under the skin's surface.

After Advanced Exfoliation, you may experience redness, flaking, peeling, itching, dryness, tingling, stinging, irritation, heat, swelling, blistering, cold sores, allergic reactions, pimples, tenderness, scarring, discoloration. In addition, dermaplaning may result in abrasions or nicks to the skin from the sharp blade. Most side effects are temporary and will dissipate within 3-7 days.

Higher level spicule treatments, especially the Time Machine protocol, may cause significant post treatment peeling that can last beyond a week. This is why there is a required second visit scheduled within 10 days after the application of the Time Machine protocol so that a treatment to address any peeling or hydration issues can be applied. The cost of the required second visit is included in the price paid for the Time Machine protocol.

All Advanced Exfoliation can make discoloration or hyperpigmentation look worse temporarily, as pigmented layers under the top layer rise as the skin growth cycle progresses. This is usually a short term issue if treatment is continued. This is one of the reasons why a series and recommended home care are important.

In order to see significant results overall, these treatments need to be done in a series, and in combination with active ingredient skin care products recommended by Calm Beauty Brooklyn.

Light, Heat and Electrical Current Skin Therapies:

These skin therapies are used to tone and tighten skin and/or muscles. The possible side effects can be the same as Advanced Exfoliation therapies above and dissipate in 3 - 7. days. Additonally, possible nausea, dizziness or headache can occur and usually dissipate in a few hours.

Micro-phototherapy: the application of bright light and heat for acne, dark spots or skin rejuvenation. Also has exfoliating properties.

Light Emitting Diode (LED): A very bright, non-UV light, positioned over the treatment area for 15 minutes. Used to calm the skin, create oxygen below the surface to inhibit bacteria.

Radio Frequency: Uses mild heat and massages the skin to help with loss of elasticity (ie., mild to moderate sagging), tightens, firms, boosts collagen/elastin synthesis; increases skin thickness; refines pores.

Micro-current: Mild electrical current applied to skin with metal probes and gel conductor, to tone skin and muscles, stimulate nerves, and reduce some forms of pain. You may experience tingling or metallic taste during treatment.

Massage:

Used to soothe skin and nervous system, tone or relax muscles. Possible Side Effects: redness, tenderness, swelling, cold sore activation, headache, inital sagging as the tissue releases then firms later. Do not have this treatment if you have recently had facial or neck treatment or surgery, suffer from an acute face, neck or scalp injury, infectious disease, active herpes/cold sores, acute dental issues, uncontrolled thyroid disease, lymphatic system infections or blockages; take medications or herbs that thin blood/cause skin to easily bruise.

Buccal Massage &/or Myofascial Facial Massage: focuses on muscles of facial expression and can be performed inside (intra-oral) and/or outside of the mouth and cheeks. In addition to Massage side effects above, Buccal/Myofascial is also not suitable for those who are pregnant, have epilepsy, recent use of Botox or fillers, undergoing cancer treatment.

Gua Sha: the use of a stone to relax muscles and move lymphatic fluids.
Lifestyle factors that affect skin health and facial choices:
Occupation or how you spend your day*
On a scale of 1-10, what's your stress level?
How many hours a day are you on electronic devices?*
Do you smoke?*

yesnoused to smoke but not now
If you exercise, what types and how often?*
What types of alcohol do you drink and how many per week?
What time do you go to sleep and wake up?
How many hours per week do you spend outdoors?
Confidential Health History - Important: please disclose ALL health information so that I can plan safe and effective treatments and reduce the risk of any adverse reactions.

List everything, even if you don't think it relates to your skin.
If you've ever been under the care of a dermatologist or plastic surgeon - List all treatments, dates, complications. Include all oral/topical medications, skin products, injectables (fillers, Botox, etc), surgeries, and all other procedures. If none, write "N/A".*
List ALL medical/dental condition(s) you have. Include treatments, dates, and any complications (example, thyroid condition, 3/2014, surgical removal of thyroid, synthroid medication, no complications). If none, write "n/a". If none, write "None".*
If not previously listed, please list ALL other OTC and prescription medications, vitamins and herbs used in the last year (including topicals, contraceptives, HRT, inhalers, etc.) and the reason for using them. Also include any type of vaccine (tetanus, flu, covid, pneumococcal, herpes zoster). If none, write "None"*
Have you ever been treated for any type of cancer? Include type(s), ALL testing, treatments, surgeries, dates, and complications. For example, breast cancer, Stage 4, 3/2014, chemo, removal of lymph nodes, caused edema). If not applicable, write "N/A".*
Pregnancy status (check all that apply)*

pregnanttrying to conceiverecovering from miscarriage in the last 6 monthsdelivered baby in the last 6 monthslactatingnone of these
Please list ANY and ALL allergies and sensitivities. If none, write "None"*
Have you ever had a reaction to hair color?
Skin Care Regimen

Please provide a COMPLETE list (brand and type) of ALL skin care products currently used, including makeup; ex., Cetaphil Cleanser, etc.
Cleanser(s)*
Toner*
Treatment Products (scrubs, peels, masks, serums)*
Eye Cream*
Moisturizers (day and night)*
SPF (type and number, ie., Eminence Bright Skin 30spf*
Foundation, Concealer, Primer, Cheek Color
Date of last facial and what they did for you (if none, write "n/a")*
Other factors that affect your facial
Massage Therapy

Many facials include massage of face, neck and shoulders.
What kind of massage pressure do you prefer?*

Light pressureMedium pressureDeep pressure
Do you prefer -*

ExtractionsNo extractionsNot sure
Do you wear -*

contactshearing aidwigdentureshair extensionslash extensionsface/body piercingnone of the above
Are you prone to -*

cystic acne (large painful, deep cysts)hyper-pigmentation (easily get brown/red marks)cold soreskeloid or hyper-trophic scars (raised scars)none of these
Skin pigment sensitivity factors (check all that apply)*

auto-immune disease related to photo-sensitivity (lupus, vitiligo, porphyria, polymorphic light eruption, sun allergy, uticaria, etc.)use of medications that cause light sensitivityuse of hydroquinone or other skin lighteners in the last 6 monthsuse of anti-depressants in the last yearuse of birth control in the last yearuse of allergy or cold medicines in the last 3 monthsuse of antibiotics in the last yearAfrican or deep black skin tone or ancestors with this pigmentationAsian ancestryMediterranean ancestryNative American ancestryNative Alaskan ancestryuse of tanning beds in the last yearsun exposure that caused a sunburn or tan in the last 6 monthsnone of the aboveOther
Skin barrier impairments (check all that apply).*

use of Accutane in the last 12 monthsuse of Retin A, Renova, Trentenoin in the last 6 monthschemical peel (TCA, Glycolic, etc.) in the last 10 daysuse of AHA, retinol, home peel in the last 7 daysuse of benzoyl peroxide in the last 7 dayslaser resurfacing in the past 12 monthsfacial piercings or tattoos in the last 6 weekspermanent cosmetics in the last 6 weeksmicro-blading in the last 6 weekshair removal process (home kit or professional, threading, waxing, depilatory, laser, electrolysis, etc.) on the area to be treated in the last 7 dayseczema or dermatitisuse of skin thinning products, drugs, herbs, etc. (ie., topical or oral steroids)psoriasisnone of theseOther
Do you have -*

claustrophobiamigrainesseizure disorders, epilepsy, etc.pacemakerhearing aidthyroid conditionmetal implants (pins, plates, etc.)embolism, thrombosis, phlebitiscardiac/heart problemsinsulin pumpdental fillingsdental bracesnone of theseOther
After your facial

Home Care is Crucial

By choosing to undergo any of these treatments, you must use daily sun protection and follow other home care procedures specifically recommended by Calm Beauty Brooklyn, which may include the purchase of products.

You must minimize sun exposure, excess heat and irritants to prevent negative outcomes since your skin will be more sensitive after advanced exfoliation.

Additional instructions:

- Avoid cleansing your skin after your treatment (same day). After the treatment day, use only post-treatment products recommended by Calm Beauty Brooklyn. When cleansing, use only cool water and your hands; do not use wash cloths, scrubs, enzymes, peels, sponges, facial brushes, nothing that exfoliates or irritates your skin.

- Avoid the sun. After the treatment you'll be wearing a mineral based sunscreen, but you’ll need to reapply every 2 hours, or after swimming or cleansing. Avoid prolonged sun exposure for 72 hours. Wear 30 spf regularly after treatment.

- Do not pick, pull, scratch or otherwise aggravate your skin. You can splash your face with cool water and pat skin to remove excess moisture, but any more activity can cause complications.

- Computers and fluorescent lighting emit UV light, so sunscreen and/or computer UV shields should be used.

- Do not drink any alcohol or coffee. These can make your skin warm, inhibit circulation, and decrease hydration.

- Avoid activities that heat your skin - exercise, saunas, steam rooms, hot showers, hot water, intense cooking with steam, hair dryers, hot curlers near skin, anything that makes your skin warm.

- Avoid liquid make up for at least 72 hours.

- Do not exfoliate or remove hair - Wait 7 days, except for Time Machine (you will not exfoliate until advised by Calm Beauty Brooklyn at the second visit). Exfoliation includes, but is not limited to wax, threading, sugaring, laser, peels, spicules, scrubs, brushes, alpha hydroxyl products, benzoyl peroxide, any vitamin A product including Retin A/Tretinoin, Renova, retinol, or Osmosis Facial Infusion, Vitamin C, active serums, anything that exfoliates, including hair removal procedures.

- If you've had Buccal or Myofascial Facial Massage, be sure to drink adequate water and rest if feeling tired or emotional. If there's any mild soreness in the days after the session, I advise to use a cold pack wrapped in a wet cloth applied to the area for a few minutes, then removed for 10 minutes, then repeated for a few rounds. This is preferable to pain relievers. Contact me if you have any questions or concerns.

- Change your pillow case, wipe down your cellphone, clean your makeup brushes, etc. Make sure to keep things that touch your skin clean.
I have completed this form truthfully and accurately.

I agree that this constitutes full disclosure and supersedes any previous verbal/written disclosures.

I understand that results are not guaranteed, and that for best results, I'll need to follow a specific home care program and/or several treatments performed in a timeframe as recommended by my skin care therapist.

I understand that facial treatments carry risks, and that withholding information or providing misinformation may result in negative reactions, including injury. I understand that my skin care therapist will take precautions to minimize or eliminate adverse reactions as much as possible. If I experience any pain, discomfort or adverse reaction during or after the service, I will immediately inform my skin care therapist.

I understand that results are dependent on many factors, including age, lifestyle, genetic traits, cumulative sun exposure, general skin condition, health, and my willingness to follow the recommended protocols and home care outlines by my skin care therapist.

I consent to photographic and/or video documentation of my progress. All photos/videos are property of Calm Beauty Brooklyn and may be used for educational and marketing purposes, however, I will not be identifiable.

Services or information provided by Calm Beauty Brooklyn or its skin care therapists are not a substitute for medical advice or medical treatment.

I certify that I am at least 18 years old, or that I am the parent or legal guardian of the above named client.

The treatments I receive by Calm Beauty Brooklyn and its skin care therapists are voluntary, and I release Calm Beauty Brooklyn and its skin care therapists from liability and assume full responsibility thereof.
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Assessing risk and your ability to benefit from skin therapies