Client Intake &amp; Consent

Client Information

Full name

Date of birth

Gender

Phone number

Email

Emergency contact name

Relationship to client

Emergency contact phone

How did you hear about Skin by Raina?

Skin Type

Your skin's natural personality and balance.

Normal

Balanced oil and water · Even texture · Tolerates products well · Comfortable

Dry

Tight after cleansing · Flakiness · Dullness · Lacks oil

Oily

Shiny surface · Visible pores · Prone to congestion · T-zone shine

Combination

Oily T-zone · Normal or dry cheeks · Zone specific needs · Mixed signals

Sensitive

Flushes easily · Reacts to fragrance · Stings or burns · Needs gentle care

Skin Conditions

Skin Concerns

What you would like addressed, and your goals for this appointment.

Current Skincare Routine

Morning routine

Evening routine

Allergies and Sensitivities

Please list all known allergies or sensitivities: skincare ingredients, fragrances, essential oils, latex, foods, medications, or anything else

Health History

Date of last menstrual period (if applicable)

Please list any current medicationsPlease add any additional detail on the above

Anything Else?

Is there anything else you would like Raina to know before your appointment?

Dermatologist Information

If you are currently working with a dermatologist, fill this in. Optional.

Dermatologist name

Practice or clinic

Dermatologist phone

Want Raina to coordinate with your dermatologist's office?

Ask about a release form

Consent and Release

Scope of Service

I understand that the services provided by Skin by Raina are performed by a licensed esthetician under the California Board of Barbering and Cosmetology, within the legal scope of an esthetician's license, and are not a substitute for medical care or advice.

Disclosure

I have disclosed all known allergies, sensitivities, medical conditions, and medications to the best of my knowledge. I understand that withholding relevant information may affect the safety or outcome of my treatment.

Assumption of Risk

I understand that skincare treatments carry some risk of allergic reaction, irritation, or other adverse response, even with full disclosure. I voluntarily assume this risk and release Skin by Raina from liability for any reaction arising from information I failed to disclose or from a pre-existing condition I was unaware of.

No Guarantee of Results

I understand that results vary by individual and that no specific outcome is guaranteed.

Cancellation Policy

I understand that a minimum of 24 hours' notice is required to reschedule or cancel an appointment.

Privacy

I understand that my personal and health information is collected solely to provide and improve my services, is kept confidential, and is not sold or shared with third parties except as required by law.

Minors

If the client is under 18 years of age, this form must be completed and signed by a parent or legal guardian, who assumes full responsibility for the consent given herein.

Governing Law

This agreement is governed by the laws of the State of California. Any dispute arising from this agreement or the services provided shall be resolved in Los Angeles County, California.

Severability

If any part of this agreement is found unenforceable, the remaining provisions will continue in full force and effect.

I have read and agree to all sections above.

I consent to before and after photos being taken and used for Skin by Raina's portfolio and marketing, with my identity kept private unless I opt in otherwise.

I am 18 or older, or I am the parent or legal guardian of the client and am signing on their behalf.

By typing your name below and checking the boxes above, you agree this constitutes your legal electronic signature under California's Uniform Electronic Transactions Act.

Signature (type full name)

Date

Parent or guardian name (if applicable)