Skincare Butik - Online Consultation Intake Form

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Please filled out this form.

Email *

Client Information

Name *

DOB *

YYYY

Address *

Preferred Contact Number *

Email *

May we leave a message if we do not reach you personally? *

Yes

How did you find out about Skincare Butik?

Google

Yelp

Facebook

Instagram

Friend

Other:

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If it was a friend, who may we thank for your referral?

Medical History

Are you pregnant? *

Yes

Maybe

Are you breastfeeding? *

Yes

Do you smoke? *

Yes

Health Conditions

Past Surgeries

Have you ever been diagnosed with Cancer? please include date of last treatment.

Please list any current medication you're taken, skincare supplements or prescription topicals *

Do you have allergies? (include aspirin & iodine) *

Do you have any Skin Conditions? *

Skin Infection

Skin Cancer

Eczema

Herpes

Hepatitis

Poor Healing

Psoriasis

Keloids/Excessive Scarring

Tattoos/Permanent Makeup

Lymph Nodes Removed

Sun Sensitivity

Easy Bruising

Diabetes

None

Required

When was your last facial treatment? Any complications? *

Did you have a ... *

Yes

Microdermabrasion

Chemical Peels

Waxing

Tanning

Laser therapy

Injections/Botox

Cosmetic Surgical Procedures

If you had any of treatments above, when was the last one? Any complications?

Skincare

What are your top 3 skin care concerns at this time?

Aging

Hyperpigmentation

Sensitivity

Redness/Rosacea

Acne/Breakouts

What type of skin do you feel you have?

Dry

Oily

Normal

Combination

Sensitive

What is your skincare routine at home? Check all that apply.

Cleanse

Tone

Exfoliate

Serum/Concentrate/Oils

Masque

Moisturize

Eye Care

Lip Care

SPF Protection

Body Care

Any additional information to share?

Treatment Consent

Please check the following boxes to give your consent. *

I agree that the nature and purpose of the treatment has been explained to me and any questions have regarding the treatment have been explained to my satisfaction.

I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.

I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.

I do not have active cold sores.

I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.

I understand that it is recommended prior to having a facial infusion to not have used Retin A for 72 hours, Accutane in 6 months or have waxed 24 hours prior to receiving treatment.

Required

Do you give consent to Skincare Butik to use photographs or videos on social media platforms. Images and or videos will not be used for any other commercial purposes *

Yes

Are you comfortable having an apprentice esthetician shadow your treatment?

Yes

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POLICY

Consultation.
Our estheticians are dedicated to helping clients achieve their skincare goals. We offer complementary consultations to better understand each individual’s skincare needs. Based on a private skin analysis and dialogue, both client and esthetician will design a treatment plan that will best meet the expectations of the client.

Scheduling.
Skincare Butik will be happy to provide your desired treatment. However, most procedures are booked several weeks in advance.

Arrival.
New clients; please arrive 15 minutes early. Upon arrival SkincareButik comprehensive skin care history and treatment consent forms will be provided. This step is key; please be thorough!

No Show/ Cancellation Policy.
We ask that you cancel or reschedule 24 hours in advance to avoid any fees. We understand that situations may arise that are out of your control so we will offer a one time, no charge same day reschedule or cancellation. After the first cancellation, you will be charged 50% of the service. You will be charged 100% for no show. We will also be charging a $25 same day rescheduling fee.

No Kids Policy.
In accordance with TDLR regulations, children are not allowed in the room during a service. Children are not allowed to be left unsupervised in the retail area due to liability. We apologize for the inconvenience, but ask that arrangements be made prior to your appointment.

Payment.
We accept cash, Visa, MasterCard & Amex. Prices subject to change without notice. Times stated are approximate.

I Agree to the Terms & Policy *

Yes

Date *

YYYY

Initials *

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