New Client Form

Contact Information
Name *
Name
Phone *
Phone
Address
Address
Emergency Phone
Emergency Phone
MEDICAL
Do you have any health problems we need to be aware of or under a Dr.’s care?
Do you have any allergies?
Have you had any recent surgery, cosmetic or medical?
Do you have implants?
Are you taking any medications (prescription/OTC)?
Are you currently, or have you taken any of the following in the past 12 months?
Please check if you have/are any of the following:
Of the Following Statements Which Apply:
Balanced Eating Habits-Check Which Apply:
Which of the following foods are you restricting?
4. Frequency of eating habits?
5. Exercise habits?
Stimulant Use Habits?
Stress Habits- check which apply?
Supplement Use
Energy – Vitality. I’d like to:
Longevity – Life enrichment. I’d like to:
Body Composition – Fat/Muscle. I’d like to:
Stress Reduction Mental and Emotional I’d like to:
SKINCARE
Have you ever had a professional skincare treatment?
Have you had a “peel” of any kind?
Have you ever had an adverse reaction to a skincare treatment or cosmetic/skincare product?
What do you consider your skin type?
Are you open to using Charlotte’s recommended product line?
SKINCARE AND WAXING POLICY: Skincare and waxing treatments provided at this location should never leave a client feeling uncomfortable. Slight redness due to stimulation is normal following skincare treatments and should go away within a few hours at the most. If breakouts occur, it is more than likely due to trapped dirt and oil that is coming to the surface. If cared for properly, using a regular cleansing and moisturizing regimen with quality products recommended by the esthetician, breakouts should disperse within a few days. If breakouts continue after a skincare treatment and proper home skincare regimen, you may be sensitive to the product being used. Consult the esthetician immediately if problems occur. Waxing can also have certain side effects; including redness, tenderness, and/or swelling. You should avoid hot water, harsh abrasives, and any sunscreen, lotion or perfume containing strong chemicals or fragrances, as they may cause irritation. After waxing or skincare treatments involving exfoliation of the skin, exposure to the sun should be limited for the next 48 hours. Be sure to ask the esthetician if you have any questions or concerns related to the treatments or post-treatment care. FACIAL, MICRODERMABRASION, CHEMICAL PEEL INFORMED CONSENT: I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximum results, I may need more than one treatment and I need to follow the maintenance home protocol. I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience actual “peeling” with this procedure, as each case is individual.I understand that there is some degree of discomfort, i.e.: stinging, “pin-pricking” sensation, hotness, or tightness. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Charlotte Savia. I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 15 is mandatory I have revealed any medical condition that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone replacement therapy or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with the exception of Accutane which must be discontinued for six months prior to treatment. I have not had a peel treatment of any kind within 14 days. I understand I cannot have another treatment until recommended by a licensed professional. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Charlotte Savia. ACNE PROGRAM: I understand that if I am participating in the Acne Treatment Program, that to achieve the results that I am hoping to for, I need to follow the treatment program prescribed to me by my esthetician. I understand that I need to use the products advised to me by Charlotte Savia. If I do not use the advised products, I understand that I may not see the results that I am looking for. PHOTOGRAPHS: I give permission for photographs to be used by Charlotte Savia for educational and/or promotional purposes. Complete patient confidentiality will be maintained at all times. PAYMENT AGREEMENT, CANCELLATION PROCEDURES, PRODUCT RETURNS: All forms of payment are accepted. Should you need to cancel or reschedule your appointment, please extend the courtesy of 24 hour notification by calling 801-448-8204 to avoid a 50% charge of your scheduled treatment to your next service. In the event of a “no-show”, you will be charged for 100% of the service at your next appointment. Should product/s need to be returned for any reason, it must be within 14 days of purchase for store credit.
Signature
Signature
I certify that all of the above information is true to the best of my knowledge. I understand that the services received here are not a substitute for medical care and any information given by the Esthetician is for education purposes only. I agree to all the policy terms stated above. If under 18 I will have a parent or guardian sign for me.