Esthetics/Nail Client Intake Form

 I agree that this form 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/nails from treatments received. The treatments I receive here are voluntary and I release this institution and/or professional from liability and assume full responsibility thereof.

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

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 understand to agree to 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 Polished Technician immediately.

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

Should I receive a Chemical Peel: Every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment. Please be aware of the following information and possible risks: I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin). I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen. I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results. I understand that results are not guaranteed and for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/ environmental damage, pigmentation levels, or acne conditions.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist.

Should I receive a hair removal service: I understand that I must disclose any topical or oral medications, new allergies or skin changes/sensitivities that may affect the integrity of the skin prior to any hair removal service.

Should I receive a Nail Service: I understand that the Polished Technician will be grooming my nails, applying appropriate massage creams, lotions and nail polishes for the desired nail service. Should the service become uncomfortable in any way I agree to make my technician fully aware should she need to make any adjustments during the service.

I have read the above information. I have accurately answered the questions within the New Client Form, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my Polished Technician to perform the treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the Polished Technician, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.  I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my Polished Technician.

 
CHANGING YOUR APPOINTMENT-
A minimum of 24 hours notice is required to reschedule or cancel a booked appointment without penalty.
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CANCELLATION + NO SHOWS-
As a courtesy, appointment reminders are sent out 48 hours prior to scheduled appointments either by text, email or both. If an appointment is cancelled or rescheduled within 24 hours of your appointment, you will be charged 50% of your service as a cancellation fee. If an appointment is cancelled or rescheduled within 4 hours of the appointment, or if you do not show up, you will be charged 100% of your service as a cancellation fee.
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SICKNESS OR FAMILY EMERGENCY-
If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. For your safety and that of staff and other clients, please do not come to your appointment sick. A one-time allowance of last minute cancellation or reschedule will be permitted for sickness or family emergency. After that, the cancellation and no show policy will be in effect.
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Consent for Treatment -I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

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Signee Information








Your Skin Care

What skin care products are you currently using? (List brand where known)










Check all that apply









Please check any that apply and explain

Health History















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Please check any/all conditions that apply to you.

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.