New Client Intake Form | Cantik Esthetics, Surrey, BC

Step 1 of 6Your details

Let’s start with you

It takes about 5 minutes. Your answers go privately and directly to Liza.

First name * Last name * Email * Phone *

Health & skin care

Are you taking anticoagulant (blood-thinning) medication? *

Yes No

Please list your medication(s)

Are you using retinol, acids or prescription skin care? *

Yes No

Which products?

Treatment history

Have you had professional esthetic treatments before? *

Yes No

Which treatments? Any past reactions or complications?

Before your treatment

Please read and confirm each item.

I understand that moles or suspicious lesions must be assessed and treated by a physician or dermatologist, and that cysts or any lesion that appears deep, inflamed or atypical require a physician’s assessment before any cosmetic procedure. I understand this is a cosmetic esthetic service, not a medical diagnosis or treatment for disease. I understand all treatments are subject to professional assessment and suitability at the time of my appointment. I understand results, outcomes and healing vary with skin condition, skin response and following aftercare instructions. I agree to reschedule if I am experiencing illness or a contagious condition. I understand thermocoagulation is a cosmetic treatment performed by a licensed esthetician. Pain tolerance varies from person to person, and comfort is managed with a topical anesthetic where appropriate and ice. Injected freezing (local anesthetic by injection), sedation and prescription pain management are not provided, as they can only be given by a regulated medical professional, such as a physician. I have read and agree to the Clinic Policies & Expectations.

Your signature

Sign below with your finger or mouse, then submit.

Sign here

Received. You’re all set.

Your intake form has been sent to Liza. She will review it before your appointment. You can close this page.

Reviewing your intake in advance is part of the Cantik experience. It allows Liza to prepare and to consult with you by phone beforehand, so your full appointment time is dedicated to your treatment.

If an intake form is not completed before a visit, please arrive 10 minutes early to complete it, as time spent on it during the appointment is taken from the booked treatment time.

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Client Intake Form

Everything stays private

Let’s start with you

Your skin goals

Health & skin care

Treatment history

Before your treatment

Your signature

Received. You’re all set.