Client Intake FormPlease fill out prior to your appointment Name * First Name Last Name Email Phone (###) ### #### How does your skin respond to sun exposure without sunscreen? Choose the option that best describes you: Type 1 - Burns without tanning. Pale skin tone often with green/blue eyes and fair/red hair Type 2 - Burns and does not tan easily. Fair skin often with blue eyes Type 3 - Burns first then tans. Fair skin with brown eyes & hair Type 4 - Burns a little & tans easily. Light brown skin, dark eyes & hair Type 5 - Easily tans & rarely burns. Brown skin, dark eyes, dark hair Type 6 - Never burns, tans to deeper tone. Dark brown/Black skin, dark eyes, dark hair How would you describe your skin type? Oily Dry Combination Normal Sensitive Have you ever experienced any burning or itching sensations on your skin after using a product? Yes No What are your long term skin goals? What are your skin concerns? Do you have any known allergies or sensitivities (skincare, food, medications)? * List any medications you currently take (including hormonal birth control or acne medications) Have you ever been diagnosed with any skin conditions? (e.g., eczema, rosacea, psoriasis) Have you ever taken accutane? Have you had any cosmetic procedures or treatments in the past 6 months (e.g., Botox, fillers, microneedling, chemical peels)? Have you used a retinoid (Such as Retin-A, Differin, Renova) or Trentinoin in the last 14 days? Yes No Would you like access to professional-grade skincare from GlyMed Plus? I can create a free account for you in my GlyMed online store, so you can shop recommended products anytime. Yes, please add me to your GlyMed store. No, thank you. Thank you! Waiver Forms Policies * At New Light Esthetics, I (Navkiran) provide personalized skincare recommendations using professional-grade products carefully selected to support your skin health and achieve your goals. To ensure product quality and the best results, I ask that you purchase recommended skincare only through authorized channels. The only authorized online store for purchases outside of my studio and this website is my GlyMed online store, available through this link: https://glymedplus.com/launch/0482222 I can send you personalized product recommendations through this store to match your skin’s needs and your treatment plan. If you choose to purchase products from unauthorized sources — such as Amazon, third-party websites, or retailers not affiliated with the brand — please understand that product authenticity, safety, and results cannot be guaranteed. In these cases, I may not be able to provide full product support or ongoing skin coaching. By checking here, I agree to Navkiran's product purchase policy. Client Code of Conduct * To ensure a respectful and professional environment, all clients agree to the following: • Professional Boundaries: All communication and behavior must remain respectful and professional. Flirtatious, inappropriate, or suggestive comments are not tolerated. • Zero Tolerance Policy: Any behavior that is harassing or makes your esthetician uncomfortable will result in service refusal and permanent ban from future bookings. • No-Shows: must follow the timeline listed in your confirmation message to avoid fees. By Checking here, I agree to the terms of client Code of conduct. * I am ultimately responsible for payment in full for services recieved, and that refunds are at the sole discretion of New Light Esthetics. I understand & Agree I consent to the services I am scheduled to recieve at New Light Esthetics. I Consent Thank you!
