FINAL Facial Intake Form

Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Today's Date

Month Day Year
Date
Birthday

Month Day Year
Date
How did you hear about Fresh Complexions? (If someone told you about me, please let me know who, so I can thank them!)
List any medications, supplements, or herbal remedies you currently take:
Do you have ANY allergies? Any product sensitivities?
Do you have any special skin problems or concerns?
Do you wear hearing aids?
Current skincare products & routine
What is your daily skin care routine? Morning and night time - and what products do you use?
Cleanser
Toner
Exfoliator/scrub
Day moisturizer

Night moisturizer

SPF

Serum

Anything else
Please check all that apply. *

High Blood Pressure Diabetes Seizures/epilepsy Pregnancy Jaw Pain / Clenching/ Grinding Metal Implants Fibromyalgia Retin -A use within the past 10 days History of cancer None of the above
Do you smoke anything or vape?

Yes No
Are you currently using any acne medication?

Yes No
Have you had any fillers (Botox, Juvederm, etc) or plastic surgery in the past six months?

Yes No
By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facial treatments (including but not limited to LED treatment, high frequency, dermaplaning, facial massage, and/or waxing services.)
2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.
3) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
4) I have clearance from my physician to receive facials.
5) I understand the risks associated with massage therapy, facials, dermaplaning and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Fresh Complexions llc and Rita Krause from all liability concerning any injuries that may occur during the treatment session.
6) I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let them know about any changes to these. I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform my aesthetician of any
discomfort I may feel during the session so he/she may adjust accordingly.
8) I understand that I or the aesthetician may terminate the session at any time.
9) I have been given a chance to ask questions about the session and my questions have been answered.
COVID-19 INFO AND LIABILITY WAIVER

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.Consent for Treatment: I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus- type symptoms?

Yes No
CANCELLATION POLICY

I appreciate your business. So that i can best serve all clients, please be advised of these policies.CHANGING YOUR APPOINTMENT
24 hours’ notice is required to reschedule or cancel a booked appointment, except in cases of contagious illness as described below. If 24 hours notice is not given, you will be charged for the appointment.
SICKNESS OR FAMILY EMERGENCY If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty in this case.
Signature *

Clear
Parents signature if client is a minor

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Current skincare products & routine

COVID-19 INFO AND LIABILITY WAIVER