Intake Form

Client Consultation

*For Minors, Parental/Guardian Consent Is Required And Can Be Completed At The End Of This Form*
Client Full Name *

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Date

MonthDayYear
Date
How did you hear about us?
Is the Client Under 18 Years of Age? *
RetinoidsAHA’s/BHA’sBenzoyl PeroxideOral AntibioticsHormonal Treatments (e.g. Birth control, HRT, etc)
If you selected any of the above, please specify how often you use each one (e.g., daily, weekly, spot treatment only) :
List any other medications, supplements, or herbal remedies you currently take:
Please list allergies or sensitivities: (N/A if none apply) *
What are your specific concerns at this time regarding your skin?
LowAverageSomewhat StressedVery Stressed
Please list Injuries or surgeries:
Have you previously received any professional skin care treatments?*
If yes, what treatments have you received and when?(e.g. facials, microneedling, chemical peels, waxing, etc.)
NormalOilyAcneDryAgingCombinationSensitiveRosaceaOtherUnsure
What is your daily skin care regimen?*
Do You Wear Sunscreen Daily? *
How often are you exposed to the sun?(With or Without Sunscreen) *
Do you use tanning beds or artificial tanning methods?*
If yes, how often and when was your last session?
What is your primary desired outcome for this facial treatment?
PregnantPostpartumNeck PainBack PainHeadachesHigh Blood PressureBruise EasilyDiabetesSeizuresJaw Pain / Clenching/ GrindingMetal ImplantsFibromyalgiaNone of the above
Retin-A or other Vitamin A derivativesAdapalene / DifferinRetinol (within the past 10 days)Prescription acne medicationsNone ApplyOther(list below)
Please List Here
I – Very fair, always burnsII – Fair, usually burnsIII – Medium, sometimes mild burnIV – Olive, rarely burnsV – Brown, very rarely burnsVI – Deeply pigmented dark brown to black, never burnsUnsure
By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive massage, facials 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 and massage therapy.
5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Cindy Veloura Beauty and the individual esthetician from all liability concerning these injuries that may occur during the massage session.
6) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician 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 esthetician of any
discomfort I may feel during the session so he/she may adjust accordingly.

8)I understand and consent to being photographed and/or recorded during the treatment as needed.

9)I also consent to the use of these photographs and videos for marketing purposes, with the understanding that my identity will be kept confidential.

10) I understand that I or the service provider may terminate the session at any
time.

11) I have been given a chance to ask questions about the session
and my questions have been answered.
Signature*
- Parent/Guardian Full Name *
  
  First NameLast Name
- Relationship to Client: *
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- I, the undersigned, am the parent or legal guardian of the minor client listed above. I give my permission for them to receive professional esthetic services at Cindy Veloura Beauty. I understand that these services may involve the use of skincare products and/or hair removal techniques that can cause temporary redness, irritation, or sensitivity. I confirm that the information provided is accurate and that I understand the risks involved.
- Signature*
- Should be Empty:

Client Consultation