Client Form

Client Form

Name *
Address: *
Phone Number *
Email address *
Have you recently had cosmetic surgery? *	Yes No
Are you clausterphobic? *	Yes No
Do you spend a lot of time in the sun? *	Yes No
Do you wear sunscreen? *	Yes No
Are you pregnant?	Yes No
What is your skin type? (oily, combination, normal, dry) *
Are you currently using skin care products? *	Yes No
If so, please explain:
Have you been diagnosed with any skin disorders? (ex. acne, rosacea, psoriasis) *	Yes No
If so, please explain disorder and medications prescribed for this:
Are you taking antihistimines? *	Yes No
Are you taking birth control or hormonal therapies?	Yes No
Are you taking accutane or using topical Retin A treatments? *	Yes No
Do you have any allergies to fragrance, essential oils, plants, nuts or vegetables that can be used in skin care? *
I understand that if I am using accutane, Retin A, or have used any exfoliants on my skin prior to my treatment that it will cause severe redness and irritation and that I will inform my esthetician prior to my waxing or facial services. (Please type your full name here if you agree) *
Do you have any heart conditions, wear a pace maker or suffer from seizures or epilepsy?	Yes No
Do you have any sensitivity to certain scents such as essential oils? *
If I have an undisclosed allergy to any ingredients used, known or unknown to me, I can not hold my therapist responsible for reactions to skin care products. However, I will contact Ellen Olson Esthetics if any reactions may occur so that the product manufacturer can be contacted and informed. (Please type your name here for consent) *
I understand that enzymes and peels used in my services are extremely active and may cause some sensitivity and peeling as a result of any peel. I give consent to my skin care therapist to use these peels as discussed during my treatment. *
If I experience any discomfort during my treatment, I will inform my skin care therapist. Please type name here if you agree) *
I am aware that post waxing or facial treatment, and sun exposure can cause my skin to burn and I understand that sun exposure should be avoided. (Please type name here to agree that you are aware of these circumstances.)
Notes, concerns and other important information:
I have read, understand and agree to all of the policies listed on the policy page of this website. (Please type your name in full if you agree) *
I have supplied credit card information to secure my reservation. If I do not show for my appointment, I understand that my credit card will be charged for the full amount of services. I understand that if I give less than 24 hours notice to cancel my appointment that I will be charged 50% of the service fee to my credit card. (type name in full to agree to cancellation/no show policy) *