New Client Intake Form

Skin Tags

Milia

Brown Spots | Pigmentation

Fine Lines | Aging

Keratosis

Acne | Milia

Sensitivity | Redness

Other (short answer)

Face

Neck

Chest

Body

Multiple Areas

Yes

No

I confirm that moles or suspicious lesions must be assessed and treated by a licensed medical doctor or dermatologist.

Cysts and any lesion that appears deep, inflamed, or atypical are outside the scope of esthetic treatment and require assessment by a medical doctor or dermatologist prior to any cosmetic procedure.and that individual results, healing times, and outcomes vary.*

 I understand that this is a cosmetic esthetic service and not a medical diagnosis or treatment for disease.*

Yes

No

I understand that all treatments are subject to professional assessment and treatment suitability at the time of my appointment.*

I understand that individual results, treatment outcomes, and healing responses vary based on factors including skin condition, skin response, and adherence to aftercare instructions.*

 I agree to reschedule my appointment if I am experiencing symptoms of illness or a contagious condition.*

I have read and agree to the Clinic Policies & ExpectationsClinic Policies & Expectations*

I understand that thermocoagulation is a cosmetic esthetic procedure. Individual comfort levels and pain tolerance vary, and temporary discomfort may occur during treatment. Ice and topical numbing products may be used when appropriate. Injectable anesthetics, sedation, and medical pain management are not provided, as these are outside the scope of cosmetic esthetic services.*