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Beautiful Reflections Client Intake & Consent

Before your Appointment:

Skip exfoliants and retinoids for about five days before your visit if possible.
Think about your skin goals and jot down any questions - I love hearing what matters most to you.
Come with an open heart and a relaxed mind.

This YOUR time. This is the next step in your Skin Journey. Take a breath, slow down, and answer from a place of self-care. Every detail you share helps me personalize your experience and support your skin from the inside out.

First name*

Last name*

Email*

Phone

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Birthday*

Month

Day

Year

How did you hear about us?*

Occupation, or simply how you spend most of your time:*

Your primary reason for visiting + your skin goals:*

Have you ever had a facial / skincare treatment?*

Yes

If yes, when was the date of your last treatment?

Month

Day

Year

Have you ever or do you currently use a dermatologist?*

Yes

Every skin has a story - which description best matches yours?*

I. Fair complexion: always burns, never tans

II. Fair light complexion: burns easily, tans with difficulty

III. Light complexion: sometimes burns, tans gradually

IV. Medium complexion: rarely burns, tans easily

V. Brown complexion: rarely to never burns, always tans

VI. Dark brown or black complexion: tans easily, may never burn

How would you describe your skin most days?*

Oily

Normal to Oily (Combo)

Normal (No excess oil or dryness)

Normal to Dry

Dry

What's been bothering you most about your skin lately? (Check all that apply)

Acne

Acne Scarring

Enlarged Pores

Dryness

Texture

Wrinkles

Fine Lines

Redness/ Ruddiness

Broken Capillaries

Age Spots

Pigmentation

Sun Damage

Sensitivity

Have you ever received any of the following treatments? (Check all that apply)

Microdermabrasion

Chemical Peel

Laser Resurfacing

Dermaplaning

Microneedling

HydraFacial

If yes to any, what was the date of your last treatment?

Month

Day

Year

Do you currently or have you ever used Tretinoin, Retin-A, Renova, Differen, Adapalene Hydroxl Acid, or any vitamin A derivative products, such as retinal? *

Yes

If yes, when was the date last used?

Month

Day

Year

Have you ever used any oral acne medication such as Acutane?*

Yes

If yes, when was the date last used?

Month

Day

Year

Tell me about any products you are currently using.*

Have you recently used self tanning lotion, had a professional spray tan or used a tanning bed?*

Yes, self tanning lotion

Yes, professional spray tan

Yes, tanning bed

If yes, when was the date last used?

Month

Day

Year

Have you used any of the following hair removal methods in the last 6 months? (Check all that apply)

Shaving

Waxing

Tweezing

Threading

Depilatories (Nair)

Electrolysis

Have you ever received any of these cosmetic injections? (Check all that apply)*

Botox

Cosmetic Filler

Collagen or Fat

Threads

If yes, when was the date of your last service?

Month

Day

Year

Do you wear sunscreen / SPF daily?*

Yes

Have you ever had any of these skin conditions? (Check all that apply)

Sunburn

Rosacea

Skin Tags

Warts

Moles

Active Acne

Cold Sores

Eczema

Are you currently taking any type of blood thinner?*

Yes

Are you currently taking any type of antibiotic?*

Yes

Have you ever been diagnosed with an autoimmune disorder?*

Yes

Have you ever been diagnosed with cancer?*

Yes

Do you smoke?*

Yes

How often do you work out?

How would you describe your diet?*

Very Healthy

Mostly Healthy

Average

Very Poor

On average, how would you describe your current stress levels?*

I rarely feel stressed.

I feel somewhat stressed.

I feel stressed most of the time.

I always feel stressed.

ALLERGIES: (Check all that apply)*

Cosmetics

Fragrances

Sunscreen

Iodine

Pollen

Latex

Shellfish

Alpha Hydroxy Acids

Animals

Aspirin

Milk

Drugs

Nuts

None

Other

FEMALE CLIENTS ONLY:

Are you currently taking any oral contraceptives? (Birth Control)

Yes

Any recent changes to or from contaceptive methods?

Yes

If yes, please specify:

Are you pregnant or planning to become pregnant?

Yes, I am pregnant.

Yes, I plan to become pregnant.

No.

Are you lactating?

Yes

Are you experiencing menopause?

Yes

Are you currently undergoing any hormone replacement therapy?

Yes

If yes, please specify:

MALE CLIENTS ONLY:

What is your currently shaving system?

Wet Shave

Electric

Do you experience irritation from shaving?

Yes

______________________________________

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatment received. The treatments I receive here are voluntary and I release this institution and/or skincare professional from liability and assume full responsibility thereof.

Signature*

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Date*

Month

Day

Year

PERSONAL PREFERENCES:

What kind of appointment do you prefer? (Check all that apply)*

Quiet - Just tell me what I need to know

I like to talk

I like a balance of talking and quiet

I like to know what you're doing at each step of the treatment

I would like to hear a healing meditation during my treatment

I like to take my time for these appointments without being in a rush

I like the treatment done as quickly as possible (in and out)

CONSENT:

I hereby consent to and authorize the following procedure: (What are you having done today?)*

Do you consent to have photos / videos to be taken in order for us to share for social media / marketing purposes?*

Yes, feel free to share them.

No, please do not share them.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by my esthetician WENDY SCHULTZ.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I do not hold the esthetician, whose name appears above, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

I have read an fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.

Signature*

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Date*

Month

Day

Year