Consent Form | Wildflower Esthetics

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Wildflower Esthetics Maine

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(207)380-3876

Client Intake & Consent Form

First name*

Last name*

Email*

Date of birth*

Month

Day

Year

Phone*

Email*

Emergency Contact Name*

Emergency Contact Number*

Have you received professional skincare services before?*

Do you have any of the following conditions?*

Acne

Rosacea

Eczema

Psoriasis

Sensitive Skin

Hyperpigmentation

None

Other

Do you have any allergies (ingredients, medications, latex, etc.)?*

Are you currently under a physician’s care?*

Are you currently taking any medications or using prescription skincare (e.g. Accutane, Retinol, antibiotics)?*

Are you pregnant or nursing?*

What is your current skincare routine? (Optional short answer)

Do you regularly use SPF? (Yes / No / Sometimes)

I have read, understand, and agree to the Client Consent & Treatment Policy.

Signature

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Contact

(207)380-3876

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