Level 1-3 Form | Taylor'd Aesthetics

Level 1–3 Treatment Consent & Intake Form

Full name

Date of Birth

Month

Day

Year

Phone

Do you have any allergies?

Medications, foods, skincare ingredients, latex, etc.

Are you currently using tretinoin, Accutane (isotretinoin), or any other prescription acne medications?

Are you pregnant or breastfeeding?

Yes

Do you have any known medical conditions we should be aware of?

Have you had any recent cosmetic treatments (facials, peels, laser, microneedling) in the last 30 days?

What is your main skin concern today?

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

What would you like to achieve with today’s treatment?

Do you consent to photos and/or videos being taken during your treatment for educational or marketing purposes?

Yes, I consent

No, I do not consent

I understand that skincare treatments can cause temporary redness, sensitivity, or irritation.
I understand that results vary depending on skin type, lifestyle, and commitment to aftercare.
I release Taylor’d Aesthetics and my esthetician from liability for any reactions that may occur as a result of disclosed or undisclosed conditions or products used.

Signature

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Todays Date

Month

Day

Year