client intake form template esthetician

Esthetician Client Intake and Consent Form

Instructions for Use

• Print this document or distribute it digitally to new clients prior to their first scheduled service.
• Ensure the client initials every numbered clause to verify they have read and understood the terms of service.
• Retain the completed, signed document in the client’s secure file for a minimum of [Number] years or as required by local record-keeping regulations.

Parties & Definitions

This Intake Form is entered into by and between [Esthetician or Business Name] (“Provider”) and [Client Full Legal Name] (“Client”).

Client Information: Date of Birth: [] Phone: [] Email: [] Emergency Contact Name/Phone: []

Operative Terms and Conditions

1. Medical History Disclosure: Client warrants that all information provided regarding medical history, allergies, surgeries, current medications, and skin conditions is accurate and complete. Client agrees to inform Provider of any changes to this information prior to future services. [ ] I confirm my medical history is accurate.

2. Informed Consent for Services: Client understands that esthetic procedures (including but not limited to facials, chemical peels, waxing, or microdermabrasion) carry inherent risks, including but not limited to redness, swelling, irritation, or temporary pigment changes. Client voluntarily assumes these risks. [ ] I consent to the services provided.

3. Contraindications: Client acknowledges that certain health conditions (e.g., pregnancy, use of Retin-A/Accutane, active infections) may contraindicate specific treatments. Client has disclosed all such conditions to the Provider. [ ] I have disclosed all relevant conditions.

4. Cancellation and No-Show Policy: Client agrees to provide at least [Number] hours' notice for cancellations. Failure to provide sufficient notice may result in a fee of $[Amount] or forfeiture of any pre-paid deposits. [ ] I agree to the cancellation policy.

5. Limitation of Liability: To the maximum extent permitted by law, Client hereby releases, indemnifies, and holds harmless [Provider Name] from any claims, demands, or causes of action arising out of or related to any loss, damage, or injury that may be sustained by the Client while on the premises or during the administration of services. [ ] I acknowledge this release of liability.

6. Privacy and Data Protection: Provider agrees to maintain the confidentiality of Client’s personal and medical information in accordance with applicable data privacy laws. Information will not be shared with third parties without express written consent. [ ] I acknowledge the privacy policy.

Signature & Acknowledgment

By signing below, I certify that I have read, understood, and agree to the terms set forth in this document.

Signature: __________ Printed Name: [] Title: [Client] Date: []

Legal Disclaimer: This document is a general framework intended for informational purposes only. It does not constitute legal advice. Esthetician services are subject to specific state or provincial licensing and health regulations; you must consult with qualified legal counsel in your jurisdiction to ensure this document complies with local laws and professional standards.