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4860 N. Clark St, Chicago, IL 60640

773.675.1918

www.revivemassagechicago.com

Skin Care - New Client Intake Form

I agree that all of the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment, in addition to home care products to receive the desired results. Results can not be guaranteed due to individual skin types and conditions.

For all resurfacing/retexturizing treatments, including Chemical Peels, Microdermabrasion and Micro-needling, you may experience some temporary redness, stinging, scabbing, blisters, pigmentation or warm flushing. During the next few hours, you may experience some tightening of the skin which may last for several days. A light flaking may begin in 48 hours and may last for several days, it is impossible to pre-determine how much peeling will occur. Lack of flaking or peeling is NOT an indication that the treatment was unsuccessful. If you do not notice actual peeling or flaking, you are still experiencing all of the benefits of your treatment such as improved skin tone, texture, and reduction of fines lines. There are a number of reasons why some people may not experience peeling such as severe sun damage, having peels regularly with short intervals, and frequent use of Retin-A, Retinol, or other AHA's. Individuals with sensitive skin, open sores, (including active Herpes Simplex), inflammatory Rosacea, or skin rashes should avoid resurfacing treatments. All skin types, especially medium to dark color skin or with high levels of melanin, are prone to hyperpigmentation (darker spots) or hypopigmentation (loss of pigment or lighter skin tone). We highly recommend you use a brightening/lightening product for at least 2 weeks prior to treatment to reduce/prevent unwanted pigmentation/complications. In addition, you should avoid the use of tanning beds, any waxing services on the face, Retin-A, Retinol or other AHA's for at least 7 days pre and 14 days post treatment. We also recommend avoiding any excessive sweating, hot showers, saunas, exercise or any activity that will raise your body temperature for at least 3 days post treatment. The skin may have an increased senstivity to sun exposure, and you agree to wear a moisturizer with an SPF50 (minimum) on all areas treated for at least 5 days post treament, regardless of climate.

I also agree to hold harmless and fully discharge and release forever and all time the officers, directors, employees, staff members, agents, contractors, successors and assign of Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC from any costs, expenses, or other liability whatsoever, including but not limited to attorneys' fees, compensatory, punitive, exemplary, consequential and special damages of any kind whatsoever, resulting from the service I have voluntarily chosen to undergo and any condition or result, known or unknown, that may arise as a result of such procedure or any other treatment I receive. I understand that I must inform the Esthetician or Technician performing my service of any changes to my skin and health prior to receiving any additional services/treatments in the future. As of May 4, 2024, I am of lawful age (18) and have read and fully understand the contents of this document and represent myself as physically capable of using the service offered by Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC.

​By signing this document, I agree that I have had sufficient time to read this entire document and ask any questions regarding the treatment I have elected to receive. Furthermore, my signature indicates that I have read and understand the information in the consent, and I understand all of the risks and potential complications connected to the procedure I have elected to undergo. I understand that the results of the treatment varies on an individual basis and that specific results are not guaranteed. I understand that while every precaution will be taken to prevent complications and that while complications from this procedure are rare, they can and sometimes do occur.

Cancellation Policy:Our Team of Licensed Professionals are only paid when they provide a service and only come to work when they have an appointment, so it is imperative that you provide us with at least 24 hours notice should you need to change or cancel your appointment. It is how they make a living and provide for themselves and families. Your appointment is reserving time on their calendar and it is preventing another client from doing the same. All that we ask is that you extend the courtesy to notify us in a timely manner (24 hours) should something change and you are unable to keep your appointment. If you cancel the same day or fail to show up for your appointment, your credit card that you provided to make the reservation will be charged for the entire amount of the service and you will be required to pre-pay for any future appointments, including past missed appointments. If you have an outstanding gift certificate, package credit or reward points, it will be redeemed for your missed appointment. By signing this document, you agree to and understand our cancellation policyand forfeit any right to dispute/reverse or otherwise deny a credit card transaction.

Product Sales/Gift Cards/Gift Certificates/Packages: All product sales are final and are non-refundable. In addition, Gift Certificates/Gift Cards and Packages for all services are non-refundable regardless if they were purchased online or in-store.

 




First Client's Name

First Name*

Middle Name

Last Name*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Client Contact Information:

Cell Phone Number (no dashes): *

Referred by
Emergency Contact

Emergency Contact *

Emergency Contact Phone Number *
General Wellness
Are you currently under the care of a Physician/Dermatologist to treat a skin condition?*
No
Yes

If Yes, please explain
Are you allergic to any of the following items: (please select below)*
No
Yes
None
Aspirin
Milk
Apples
Citrus
Grapes
Latex
Fish
Iodine
Sulfur
Other:

If Yes, indicate details and date:
Skin Care Regimen - 80% of Your skin's health/appearance depends on what products you are using on your skin 365 days a year. You will never reach your skin care goals by depending on infrequent Spa Treatments and using low quality skin care at home.

What are your specific conerns/challenges with your skin? *

What skin care products are you currently using to address your skin concerns?


Cleanser:

Exfoliants/Scrubs:

Serums:

Toner:

Moisturizer:

Masks:

SPF:

Other:
Are you happy with the results from the products you are using?*
No
Yes
Skin Care Treatment History
Are you currently having skin treatments (Botox, Laser Resurfacing, Laser Hair Removal, Chemcial Peels, LED Light Treatment), etc?*
No
Yes

If Yes, indicate treatment and frequency
Are you currently using any of the below products on your skin? *
None
Benzoyl Peroxide
Glycolic Acid
Lactic Acid
Salicylic Acid
Retinol
Are you currently using any of the below topical medications on your skin? *
None
Tretinoin (Retin A, Renova, Avita)
Adepalene (Differin)
Azelaic Acid (Azelex, Finacea)
Isotretinoin (Accutane)

Please list any other topical antibiotics that may not be listed above
Are you currently experiencing or have you ever experienced any of the following conditions: *
None
Skin Cancer
Dermatitis
Keloid Scarring
Acne
Rosacea
Broken Capillaries
Hypopigmentation
Hyperpigmentation
Treatment reactions

If you checked any of the above conditions or have a condition not listed, please describe.
Waxing Services
Have you had any adverse reactions to waxing in the past (ingrown hairs, breakouts, Hyperpigmentation, Hypopigmentation, etc?*
No
Yes

If Yes, please explain:
We advise that you stay out of the sun/tanning beds 48 Hrs before & after your waxing appointment. You should begin to exfoliate the area to be waxed 1 day before your appointment and resume exfoliating 48 hours after to prevent ingrown hairs. You must exfoliate and moisturize the area to reduce/prevent ingrown hairs. 

All skin types, especially medium to dark color skin or with high levels of melanin, are prone to either hyperpigmentation or hypopigmentation (areas of discoloration or uneven color). We recommend a brightening/lightening product or treatment to reduce unwanted pigmentation, as well as the daily use of a SPF50 or higher.


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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