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Viva Lumière Wellness – Confidential Skin Health & Client Intake Form

Birthday
Month
Day
Year
Referred by:
3. Have you ever had facial treatment in the past ?
Yes
No
4. How would you describe your skin?
5. How would your rate your skin?
6. What is your present skin regiment?
7. Do you Blush easily?
If yes, what are the contributing factors?
8. Do you ever experience
9. Have you ever had
10. Are you under treatment for any current skin conditions?
11. Does your skin heal
12. Do you bruise easily?
13. Do you get sores/blisters (Herpes Zoster/Shingles)?
Have you ever used
15. Any personal or family history of skin cancer?
Yes
No
16. How would you describe your overall health?
17. Have you had any of the following, past or present?
18. Have you ever had a reaction to
20. How is your stress level
21. Do you normally sleep well?
22. Do you exercise regularly?
23. Do you have food intolerances
24. Do you follow any special diet?
26. How many cups of caffeine - type beverage ( coffee, tea, soft drinks) do you consume daily
27. We may suggest updates to your home care routine for best results. Would that be okay with you?

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral. In order to achieve your skin improvement goals

INFORMED CONSENT RELEASE

I, as the client booking this appointment, do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon y age, skin condition and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concern regarding my treatment or suggested home product routine. I will inform my skin care professional immediately.


I release and hold harmless the skin cares professional Vivian Yu at Viva Lumiere Wellness, and the staff harmless from any liability for adverse reactions that may result from this treatment.


POLICIES


General Booking Terms (Excludes Face Reality® Bootcamp)

  • All appointments must be prepaid in full at the time of booking.

  • Appointments may be rescheduled or canceled with at least 48 hours’ notice with no penalty.

  • Cancellations made within 48 hours of your appointment will result in a $50 late cancellation fee. The remaining balance may be applied toward a future service.

  • No-shows will result in the forfeiture of your full payment.

  • All sales are final. No refunds.

Booking & Cancellation Terms for Face Reality® Bootcamp

  • All Face Reality® bookings, including consultations and follow-up sessions, must be prepaid in full at the time of booking and are non-refundable. No exceptions.

  • By booking, you agree to our strict Face Reality® Cancellation and Refund Policy.

  • Cancellations made within 48 hours of the appointment will result in full forfeiture of the prepaid fee.

  • No-shows will not be rescheduled or refunded.

  • Rescheduling is permitted only if requested at least 48 hours in advance.

Acknowledgment

I, as the client booking this appointment, have read and agree to the terms and policies outlined above, including booking, cancellation, and refund terms.

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