Tuning Fork Ritual Intake Form | The Ritual Esthetics Room

First name

Last name

Birthday

Month

Day

Year

Phone

Emergency Contact Name & Phone:

Have you ever had a professional facial or skin treatment before?

Yes

If yes, when was your last treatment?

What are your main skin concerns?

What skin care products are you currently using?

Do you have any allergies (including skin products)?

Do you have any medical conditions? (e.g., diabetes, heart issues, etc.)

Have you had Reiki before?

Yes

Have you had Botox, fillers, or similar treatments?

Yes

If yes, when was your last treatment?

Are you currently taking any medications or using any medical devices (including implanted devices)? If yes, please provide details below.

Do you have any skin conditions (e.g., acne, eczema, rosacea)?

Do you have any history of cold sores or herpes?

Do you have a pacemaker or any metal implants?

Are you pregnant or breastfeeding?

Do you use tanning beds or self-tanners?

How would you describe your skin type? (Oily, Dry, Combination, Sensitive, Normal)

Do you have any sensitivities to heat, cold, or light?

Do you smoke or drink alcohol?

Is there anything else you would like to share about your skin or health?

Client Consent Form

1. I understand that skincare treatments are not a substitute for medical care.

2. I have disclosed all relevant medical and personal information to the best of my knowledge.

3. I understand that results are not guaranteed and may vary based on my skin type and care.

4. I agree to follow post-treatment instructions provided by my aesthetician.

5. I release my aesthetician and their business from any liability arising from my treatment.

6. I consent to the treatment and acknowledge that I have had the opportunity to ask questions.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

Subscribe to the newsletter