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Watercolor Eucalyptus Branch

intake & consent
Skincare Therapy

Eliane Ripka administering a lymphatic massage on the stomach of a client draped in luxurious terrycloth
Date of birth
Month
Day
Year

Health History

1. Have you ever been under the care of a dermatologist?
Yes
No
3. Do you have any of the following? (Check all that apply)

Skin Concerns & Current Routine

1. What are your main skin concerns? (Check all that apply)

Morning Routine

Evening Routine

3. Have you received any of the following in the past 30 days? (Check all that apply)

For Acne Clients Only

1. Have you used Accutane (Isotretinoin)?
Yes
No
2. Are you currently using benzoyl peroxide, salicylic acid, or retinoids (e.g., Retin-A)?
Yes
No

Consent for Treatment

I understand that the skincare treatments I receive at Levvit Wellness & Beauty are not a substitute for medical care and are intended for cosmetic purposes only. I have informed the aesthetician of all known allergies, medical conditions, and medications. I understand that individual results vary and that no guarantees are made.


I acknowledge that some treatments may involve the application of acids or exfoliants that can cause temporary redness, sensitivity, or peeling.


I give my voluntary consent to receive facial treatments, chemical peels, and/or acne treatments from Eliane Ripka.

Photo Release (Optional)

I give permission to Levvit Wellness & Beauty to take before and after photos of my skin for documentation purposes. Photos may be used anonymously for educational or promotional purposes on the website or social media.

I understand that I may decline this section without affecting my care.
Yes, I agree to the use of my photos.
No, I do not agree to the use of my photos.
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