NEW CLIENT (100% VIRTUAL CARE)

APPOINTMENT REQUEST

First Name

Last Name *

Address

Address: *

City *

State *

Country *

Postal code *

Email *

Phone *

Gender *

Source *

Are you 18+ years or older? Vanity Lab Skintique is not currently accepting teen clients unless they are referred by an existing client. *

First tell me in your own words what we can do to help you feel better about your skin. Please be specific as possible and provide full skin history. The more we know the more we can tailor a plan to your specific needs. *

What are your short and long-term goals for your skin. Short-term meaning what are your expectations today and long-term meaning where do you want to be at the end of your treatment plan? *

Tell us about your skin / what you're looking to improve or achieve by coming to Vanity Lab Skintique. Include any important information of skin history / if you've been struggling for a while. The more information the better, so we can come up with a curated plan for you.

List all current products you are using at home in your skincare routine. As well as what you like and dislike about your current routine. *

Upload a photo of the current products in your skincare routine. *

How much are you currently spending on this skincare routine? *

If other, please explain *

Have you achieved your desired results with your current routine? *

On a scale of 1-10 how do you current prioritize your skin health and where would you like to be? Ex. I'm currently at a 3 with prioritizing but would like to get to an 8 with your help. *

List all current prescriptions and over the counter supplements that you're taking. *

Are you currently, or have you even been on Accutane? *

Are you pregnant, nursing or planning to become pregnant? *

Are you currently undergoing hormone therapy replacement? *

How long have you been doing this routine? *

Do you prefer a tinted or nontinted SPF? *

Have you ever used a Retinol before? Was it OTC or Prescription? And what was your experience like with retinol use? *

How many steps is your ideal skincare routine? *

What is your budget for starting a new skincare routine? Keep in mind that a targeted and tailored regimen begins around $180. We carry several professional grade products to ensure we can work with almost any budget. Our goal is to make sure your results and home care are easily obtainable for you. *

Are you currently wearing Sunscreen daily? *

Are you currently under the care of a Dermatologist or other Skin Professional for the same concern you previously listed? *

Have you ever been under the care of an Aesthetician or Medical Injector?

Please list your history of any facials, injectables, lasers, chemical peels, microneedling, etc. As well as what you did and did not like about these treatments. *

Homecare is required for all clients wanting to seek treatments with Vanity Lab Skintique. Are you looking to make treatments a monthly / regular thing in order to meet your goals? *

Although we do not accept or run insurance, we do accept payment for professional skincare using FSA, HSA and Care Credit. Will you be using one of these for payment? *

FSA

HSA

Care Credit

Self Pay

Do you see yourself coming in studio for treatments with Keta

Any specific questions for Keta or other concerns we should know about that pertain to your skin or medical history? *

Did you see any products or homecare treatments that you were interested in at Vanity Lab? *

Please upload 3 clear, well lit, in indirect sunlight images of each side and the front of your bare, clean face. Starting with Straight on.

Straight On Photo *

Left Profile *

Right Profile *

If acne, texture, or congestion prone please upload a picture of your current makeup routine.

List any known allergies or known sensitivities that cause a reaction:

If other, please explain:

Vanity Lab Skintique is a by appointment only practice. All appointments and virtual calls are held in Central Standard Time. If we do not have your desired time available would you want to you get setup with a targeted and customized homecare regimen to start working towards your goals while we wait for your desired opening.

Policies + Liability at Vanity Lab Skintique

1. We will not treat clients with questionable medical conditions such as Herpes Simplex (active cold sores, fever blisters), open wounds or sores, healing incisions, infectious diseases, etc. We do not manage clients undergoing cancer, or systemic treatments of any specific contraindications for the body.

2. We require a minimum of 48 hours advance cancellation notice. Any client giving less will be charged 100% of the service fee. Any clients who No Call + No-Show their appointment will be charges 100% of the service fee. We will not make acceptations under any circumstance including illness.

3. A valid card must be saved on file to reserve your appointment and we will only accept payments from card that is saved on file. Removing your card or adding an invalid card will result in all appointments being canceled and booking to be restricted.

4. I understand that services received here are not a substitute for MEDICAL CARE and any information provided by the Aesthetician is for educational purposes only.

5. All information received by the client on this chart, is completely private and confidential.

6. In clinic appointments - Children are not allowed at any appointment. This is for the safety of our space and the safety of others. If you arrive to your appointment with your child, the appointment will be canceled, and you will be responsible for the late cancelation fee. We will not make acceptations under any circumstance.

7. All packages purchased in person or online must be used within 6 months of purchase date. Late cancelation fees and no-show fees will be deducted from packages if applicable

8. Multiple consecutive cancelations and or reschedules will result in booking access being restricted.

9. After 2 consecutive Cancellations, No Shows or Reschedules booking opportunities will close indefinitely. Invoice are nonrefundable under these circumstances.

10. ALL SALES (including invoices) ARE FINAL ONLINE AND IN PERSON. **Virtual Skin Evaluation are not an appointment that can be rescheduled so they are not refundable.

- Vanity Lab Skintique cannot be held responsible for any lost or missing items. Please contact the selected carrier (USPS) for assistance making an insurance claim.

- We do not accept any returns or exchanges regardless of circumstance. If an item is defective or broken, please email [email protected] with videos/pictures so we may contact the company.

Vanity Lab will take every precaution to ensure your safety and well-being throughout your treatment plan. Please review the following information regarding potential risks and confirm your understanding of the process.

I consent to and authorize Vanity Lab Skintique to perform the scheduled treatment and/or homecare oversight.

I voluntarily agree to proceed with the treatment plan and/or homecare guidance after receiving an explanation of its nature, purpose, and associated risks.
While it is not feasible to list every possible risk and complication, I have been informed about the potential benefits, risks, and complications related to the treatment.

I acknowledge that it is essential for my health and safety to provide all requested information in the Client Intake Form(s). I have disclosed my health history, including any relevant conditions, allergies, medications, supplements, or prescriptions I am currently taking (both orally and topically), as well as any past reactions to products or medications.

I recognize that no specific results are guaranteed and that I may need additional treatments and/or homecare guidance to achieve the desired results.

I have read and understood all pre-treatment and home care instructions and recognize the importance of adhering to these guidelines. If I have any further questions or concerns about my treatment plan, I will consult with the team at Vanity Lab Skintique promptly.

I acknowledge that if I have any concerns, I will discuss them with the team at Vanity Lab Skintique before proceeding with the treatment and/or homecare we've discussed. I understand that Vanity Lab Skintique will take all necessary precautions to minimize any negative reactions.

This document represents complete disclosure and overrides any previous verbal or written agreements.

I confirm that I have read and fully understand the information provided and have had the opportunity to ask questions.

I comprehend the procedure and accept the associated risks. I do not hold Vanity Lab Skintique responsible for any pre-existing conditions that were not disclosed at the time of this oversight.

I acknowledge and agree to the terms of this liability waiver.

Signature *

Clear

Please refrain from submitting unless you are ready to book and pay invoice. You will be contacted by Vanity Lab Skintique to schedule if your appointment request is accepted. Once accepted an invoice will be sent totaling the amount of the appointment you selected. All first-time and lapsed clients are required to pay for their first appointment in full via invoice.

Please note that nothing is booked, secured, or reserved until this invoice is completed.

Virtual with Vanity

We offer Virtual Skin Programs to help serve those that may not be nearby or have the time available to make the trip to Vanity Lab Skintique