New Client

If you are a new client with an appointment at the studio you need to complete an intake form. To do so, you may fill out the form below, or if you prefer click on this link to print the form, fill it out, and then bring it with you to your first appointment.

Contact Info

Your Background

EmailMobile TextPhone
YesNo
DairyPeanutsWheatFruitSoySugar
YesNo
YesNo

Skin Care History & Analysis

OilyDrySensitiveNormalCombination
AcneEnlarged poresScarring BlackheadsWrinkles/Signs of agingPigmentation issuesClogged poresRosacea
Chemical PeelsScrubsLaser/IPLMicrodermabrasionFacial BufferRetinA (tretinoin)Glycolic acidWaxElectrolysisBenzoyl PeroxideSalicylic Acidnone of the above
YesNo
YesNo
YesNo

These questions are relevant to your skin health in regards to customized treatments and want to avoid any contra-indications for these treatments. Please answer thoroughly.

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Acne/RosaceaDiabetesLight sensitivityOpen WoundsSkin inflammation disordersBell's PalsyEmbolismMelanomaSensitive skinThyroid conditionsCold SoresEpilepsyMigrainesStroke/TIANone

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your treatment, please be aware of the following information and possible risks. Please check each item indicating that you have read and understand.

I understand that there are certain risks associated with facial and body services. I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the procedure we have discussed, and will hold Cryo Cloud, LLC. harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, Cryo Cloud, LLC., responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.