ENFR

Printable · for estheticians

Esthetician intake and consent form

Print it, hand it to the client on arrival, keep it in the file. The text below is the same one clients sign when they book online through the booking software.

Printable · Filled in by hand, signed on paperv1

Esthetician intake

A few answers so your esthetician can plan a safe lash extension or microdermabrasion service. The consent wording is a starting point, not legal advice: adapt it to your province, your insurer and your professional order.

Client name

Phone

Any known allergies or sensitivities? *

  • Adhesive or glue
  • Latex
  • Fragrance
  • None of these

Eye surgery or an eye infection in the last 6 months? *

  • Yes
  • No

Do you wear contact lenses? *

  • Yes
  • No

Are you pregnant or breastfeeding? *

  • Yes
  • No

Are you using isotretinoin, or a retinoid cream on your face? *

  • Yes
  • No

Any active skin condition on the face or around the eyes (eczema, rosacea, cold sores)?

Medications or supplements that thin the blood or make the skin more sensitive?

I confirm my answers are complete and true. I understand that lash extensions and microdermabrasion can cause irritation, redness or an allergic reaction, that a patch test may be recommended, and that I will tell my esthetician about any change in my health before a visit. I consent to the service I booked.

I have read and agree to the statement above.

Signature

Printed name

Date

This form is a starting point, not legal advice. Have it reviewed for your province or state before use.

What the PDF looks likeLetter · 8.5 × 11 in

Business name

estheticians
v1

Intake and consent form

Client name
Phone

Any known allergies or sensitivities? *

  • Adhesive or glue
  • Latex
  • Fragrance
  • None of these

Eye surgery or an eye infection in the last 6 months? *

  • Yes
  • No

Do you wear contact lenses? *

  • Yes
  • No

Are you pregnant or breastfeeding? *

  • Yes
  • No

Are you using isotretinoin, or a retinoid cream on your face? *

  • Yes
  • No

Any active skin condition on the face or around the eyes (eczema, rosacea, cold sores)?

Medications or supplements that thin the blood or make the skin more sensitive?

I confirm my answers are complete and true. I understand that lash extensions and microdermabrasion can cause irritation, redness or an allergic reaction, that a patch test may be recommended, and that I will tell my esthetician about any change in my health before a visit. I consent to the service I booked.

I have read and agree to the statement above.

Signature
Printed name
Date
Free form from clevrstart · clevrstart.compage 1 of 1

See the booking for estheticians · Letter, 8.5 × 11 in, one page.