Client Portal · Skin + Self

1 · Client Information

Full Legal Name

Date of Birth

Phone Number

Email Address

Home Address

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Referred By (if applicable)

2 · Health & Skin History Please answer honestly — certain conditions, medications, and recent treatments can affect your safety or results.

If you answered "Yes" to any item above, please explain

Any medications, skin conditions, or relevant medical history not covered above

3 · Service-Specific Consent Check the service(s) you're receiving, read the consent, and add your initials. A patch test is recommended 24–48h before any new tint, lamination, or chemical service.

4 · Photo & Video Release Optional

Photos are completely optional — please hold off on uploading close-up skin photos for now. If they'd help your treatment plan, Pauline will ask at your consultation.

YES — I consent to my photos/videos being used for portfolio, marketing, and social media (face may be cropped or excluded on request).

NO — I do not consent to my photos/videos being used for any marketing purpose.

＋ Tap to add photos

5 · Policy Acknowledgment & Consent

I acknowledge the Cancellation, Late Arrival, No-Show, and Refund Policies, and understand fees may apply for late cancellations, no-shows, or arriving more than 15 minutes late.

I certify the information provided is true and accurate, I have disclosed all relevant health information, and I voluntarily consent to receive the service(s) indicated.

Signature (type full legal name)

Date

Your Account

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