New Clients

Client Intake Form

Please complete this form before your first appointment so Liza can understand your skin concerns and goals. It takes about 5 minutes.

Before you begin

Everything stays private

Your answers are used only to plan a safe, suitable treatment. Questions? Call 604-786-4847 or email liza@cantikesthetics.ca.

01
Your details
02
Your goals
03
Primary concern
Skin Tags
Milia
Brown Spots | Pigmentation
Fine Lines | Aging
Keratosis
Acne | Milia
Sensitivity | Redness
Other
04
Area of concern
Face
Neck
Chest
Body
Multiple Areas
05
Health disclosure
Are you taking anticoagulant (blood-thinning) medication?
Yes
No
I understand that moles or suspicious lesions must be assessed and treated by a licensed medical doctor or dermatologist.
I understand that cysts and any lesion that appears deep, inflamed or atypical require medical evaluation before cosmetic procedures.
I understand this is a cosmetic esthetic service and not a medical diagnosis or treatment for disease.
06
Skin care & history
Are you currently using retinol, acids or prescription skin care?
Yes
No
Have you had professional esthetic treatments before?
Yes
No
07
Treatment readiness
All treatments are subject to professional assessment and treatment suitability at the time of my appointment.
Individual results, treatment outcomes and healing responses vary based on skin condition, skin response and adherence to aftercare instructions.
I agree to reschedule if I am experiencing illness or a contagious condition.
I have read and agree to the Clinic Policies & Expectations.
08
Thermocoagulation
Thermocoagulation is a cosmetic esthetic procedure. Individual comfort levels and pain tolerance vary, and temporary discomfort may occur during treatment. Ice and topical numbing may be used; injectable anesthetics, sedation and medical pain management are not provided, as these are outside the scope of cosmetic esthetic services.
I acknowledge and understand the above.
09
Signature
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