Pregnancy Facial Intake Form

Please read each statement, initial in each box, and sign this document to accept your acknowledgment and agreement of the following:

I affirm that I am 18 years of age or older, and competent to sign this release on my own behalf. I have read and fully understand and accept this agreement and all information detailed throughout this consent and intake form. I understand the service and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician and or Kate Aglaia Aesthetics owner responsible for any of my conditions that weren’t disclosed at the time of the skin care service, which may be affected by the treatment performed. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my technician. Although it is impossible to list every potential risk and complication, I have been informed of possible risks and complications. I have also, to the best of my knowledge, given an accurate account of my medical history, including known allergies or prescription drugs or products I am currently ingesting or using topically. I understand and accept the nature and purpose of the products to be used in this service has been explained to me, along with the risks and hazards involved.

Signature

Today's Date

Full Name

Date of Birth

Month

Day

Year

Email

Phone

Address

Are you pregnant or lactating?:

Conditions you are currently experiencing today (Please select all that apply):

What type of skin do you have?:

Oily

Dry

Normal

Combination

List all allergies including plant/vegetable products, cosmetics, and medications:

What areas of concern do you have regarding your skin?:

Have you been under the care of a dermatologist within the past year?:

If yes, please explain

Have you used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products before pregnancy?

If yes, please explain

Have you received Botox, Restylane, or Collagen injections in the last 6 months?:

If yes, please explain

Do you participate in vigorous aerobic activity or sports?:

What type of facial treatment did you last have and what did you enjoy most and least about the treatment?

What improvements would you like to see in your skin?

What products do you currently use on your skin? Do you use sunscreen on a regular basis?

I hereby consent to and authorize Kate Aglaia Aesthetics to perform facial treatments on me

I give Kate Aglaia Aesthetics permission to take photos of my treatment for before-and-after comparison, educational purposes, marketing (social media), and documentation.

I understand and accept that there are risks associated with getting a facial. I understand that no warranty, guarantee, or assurance has been made to me as a result of the facial treatment and that the final result cannot be guaranteed as each skin type is unique. I further acknowledge that, as part of the procedure other potential risks can occur. I agree that if I experience any conditions during or after the procedure, I will notify Kate Aglaia Aesthetics and consult a physician at my own expense.

I fully release my technician & Kate Aglaia Aesthetics from any liability related to this procedure, during & after its completion. The procedure will be performed with utmost safety & proper technique, using tools & products the technician is trained in.

Signature

Today's Date

I understand payment is due in full at the time of service. Cancellations or rescheduling must be made 48 hours in advance, or a 50% charge applies. No-shows are charged 75%. Late arrivals (10+ mins) incur a no-show fee and must reschedule.