Peach Esthetics
intake & consent form
first name *
Your answer
last name *
Your answer
email address *
Your answer
phone # *
Your answer
address
Your answer
birthdate
MM
/
DD
/
YYYY
Referred by *
how did you hear about us?
If referred, who referred you to us?
Your answer
Are you currently, or within the last year, under a doctor’s care? *
Have you undergone any surgery in the last 9 months? *
Check any conditions you have had or are currently experiencing: *
Required
List any medications, vitamins, or supplements that you take regularly.
Your answer
Do you wear contact lenses? *
Do you have metal implants, a pacemaker or body piercings? *
Check all items that have ever caused a reaction for you: *
Required
Are you currently pregnant or lactating? *
Exfoliation History *
YES
NO
not sure
Have you ever had a chemical peel?
Have you ever had microdermabrasion?
Have you ever had laser or other resurfacing treatments?
Have you ever used Accutane, Retin-A, Renova or Adapalene?
Capillary Activity *
YES
NO
not sure
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
Any concerns or information you want us to know before starting
Your answer
SIGNATURE: By writing my name below, I am effectively providing my signature, indicating that all the information on this form is true and accurate, to the best of my knowledge. *
Your answer
Cancellation Policy *
We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance. Our estheticians want to be available for your needs and the needs of all our clients. When a client does not show up for a scheduled appointment, another client loses an opportunity to be seen. There will be a fee of $25.00 assessed if we do not receive a call to cancel an appointment at least 24 hours in advance. A no-show no-call may be charged for the full price of the appointment. Thank you for being a valued client and for your understanding and cooperation. This policy will enable us to open otherwise unused appointments to better serve the needs of all clients. By signing below, you acknowledge that you have read and understand the Cancellation Policy for Peach Esthetics as described above.
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