Skincare / Dermaplaning Intake Form

Name *

Phone # *

Cell Phone #

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country

Date of Birth *

Emergency Contact Name *

Contact Phone # *

Email Address *(To receive Appointments Reminders and Special Offers)

How did you hear about us?:

Within the last year, have you been under a dermatologist or other physicals care? *YESNO

If Yes, When and for what are you being treated for?

Within last 60 days, have you had any type of esthetic work preformed? *YESNO

If Yes, When and what did you have done?

Do you smoke? *YESNO

Do you exercise regularly? *YESNO

Do you follow a restricted diet? *YESNO

Do you wear contacts? *YESNO

How many cups of water do you consume daily? *

Have you ever had any of the following: Botox Injections , Restylane Injections, Collagen Injections, Laser Resurfacing , Rhytidectomy (Face Lift), Rhinoplasty (Nose), Blepharoplasty (Eye lift), Skin Cancer? *YESNO

If Yes, What and When?

Have you ever had any of the following: Dermaplaning, Microdermabrasion, Enzyme, Microcurrent, Micro needling, High Frenquency, Galvanic, Peels, Oxygen? *YESNO

If Yes, What and When?

YOUR SKIN

Do you experience breakouts? *YESNO

Do you ever experience oily shine during the day? *YESNO

Do you ever experience a burning, inching sensation on your skin? *YESNO

Do you drink more than 4 caffeinated beverages a day? *YESNO

What is your pain threshold? *LowMediumHigh

Do you experience irritation from shaving? *YESNO

Do you experience ingrown hairs? *YESNO

What are your skin care goals? *

Do you have any special skin problems pertaining to your face or body? *

When exposed to sun, do you? *Burn EasilyTan EasilyNever BurnNever Tan

Have you been prescribed any of the following in last six months: Accutane, Retin-A, Renova, Adapalene, or other prescribed skin medications? *YESNO

If Yes, When and What?

Please explain any checked conditions listed above and anything else you think your professional should be aware of *

Please list any medications prescribed or you are currently taking that you think your professional should be aware of *

I have agreed to have Blvd spa preform esthetics and skin care services. Before my qualified professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below. I will notify my technician at anytime during or after this treatment of any
changes to my intake form or condition changes. If you checked off or answered yes to any of the questions above, Blvd Spa advises you to see your doctor regarding the risks or hazards of the proposed treatment before signing this consent form. If you choose not to see your doctor, you must acknowledge by signing below that Blvd Spa has asked you to visit your physician to obtain medical clearance before beginning treatments. You have elected not to do so and assume all risks for any injures arising from undertaking any treatments due to a known medical condition. Blvd spa still reserves the right to not begin any treatment under these conditions.

Waiver of Liability: Although every precaution will be made to ensure your safety and well-being before, during and after your procedure please be aware that your procedure is safe and there is no recovery time for most people. I understand there are risks associated with esthetic / skin care service procedures such as but not limited to: slight pink or redness to the skin, and will subside within a few hours of finishing the treatment, bruising, skin irritation, or worsening of breakouts, hyperpigmentation, hypopigmentation, and moles may occur and resolve themselves, but have the potential of being permanent. There is also the rare possibility of texture of scars, but can occur post-treatment. As part of this procedure, I will not attribute any liability to Professional or Blvd spa as a result of this procedure. I understand that while every attempt to be made to provide you with a procedure that is exactly as you requested but every person reacts to products differently and you final results might differ from what you initially requested. I also agree to defend, indemnify and hold harmless Professional and Blvd spa from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees which might be asserted against them as a result of my having this procedure performed, or my purchase of these Blvd spa products. As used in this agreement, the terms “Professional” and “Blvd spa” include all of their respective officers, directors, agents, employees, successors and assigns.

Care and Maintenance: I agree to follow the care and maintenance instructions provided by Blvd spa and/or Professional for the use and care of my skin, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that it is possible to feel slight irritation, tightness, and/or redness. These ae all common reactions which typically resolve themselves within 48-72 hours post treatment. As every clients experience is different, some clients may experience symptoms delayed. To maximize results, we recommend our at home maintenance products. The skin needs to be protected from excessive sun exposure. It is my responsibility to avoid waxing, lasers, aggressive exfoliation, and products containing any retinoids or glycolic acids on the treated areas for at least two weeks after my treatment.

No Known Medical Conditions / Informed Consent: I have read and completed the Blvd spa Consent Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the professional’s or Blvd spa instructions or these warnings.

Disclaimer: I agree that I will not hold blvd spa and its employees liable for any injury or condition that arises from application of service despite completion of this form. This form is intended as an assessment tool only and serves as a guide for the application of service not for medical treatment or medical assessment. If I experience pain or discomfort during the session, I will immediately inform the professional so that the pressure may be adjusted. I understand that Professionals are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe or treat any physical illness, and that nothing in the course of the session given should be construed as such. Draping will be used during this session. No guarantee has been given by anyone as to the results that may be obtained by this treatment. The clients and all persons on the premises by invitation of the clients hereby hold blvd spa, its employees, independent contractors, the LLC or any individual connected in any way to blvd spa, Only the body area being worked on will be uncovered. Clients under the age of 18 must have a parent or legal guardian present to provide a signature for authorization for the
session.

I have stated all conditions that I am aware of and this information I provided is true and accurate to the best of my knowledge. I agree to inform my professional immediately of any change in the conditions stated above on every visit moving forward. This consent form will stay on file and be used for this service and all future sessions. I acknowledge that this information is confidential and intended for review by blvd spa; that a medical referral may be requested of me; and that blvd spa is not liable for the management of any condition.

Client Signature (Parent/Guardian If Minor) *

Date *

Skincare / Dermaplaning Intake Form

Please indicate your skin type *

Do you use any of the following for your facial regime?

What skin conditions would you like to improve?

PLEASE MARK ALL CURRENT AND PAST CONDITIONS *