Intake Form - Chelsea

GUEST PROFILE

Thank you for taking time to complete this consultation form. This will help your esthetician make informed decisions to help get you the results you want from your treatment and also to ensure that your treatment is carried out safely.

CONTACT INFO

 )  - 

DATE OF BIRTH

HEALTH HISTORY

CONSENT FORM

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on a facial treatment such as pregnancy, recent facial surgery, allergies and use of topical medications such as Retin–A or Accutane. I will inform the therapist of any changes in my status.

I understand that extended sun exposure is not recommended when using peel treatments and that the daily use of sunscreen protection with a minimum of SPF 30 is mandatory to 1 to 2 days after treatment.

I agree, that by signing this document, I am confirming that all my relevant medical conditions have been disclosed. I understand and acknowledge the advice and purpose of this document. I also agree that Naturopathica has no liability for any failure by me, to disclose accurately the requested information.


Your Shopping Bag


Your shopping bag is empty!
Your shopping bag is loading...
BACK TO SHOP
{{ cart_item.product_name }}
{{ cart_item.size }}
QTY
{{ cartItemPrice(cart_item) }} ( {{ cart_item.list_price * cart_item.qty | currencyStripped }} )
{{ cart_item.bundle_value_message }}
Subtotal
{{ subTotal | currency }}
{{ offer_item.message }}