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Book Appointments
Book Spa Appointments Online
STUDENT SPA MENU
COVID-19 Check List - Client Check In
Clinic Client Survey
Client Care Plan
Membership
Our Luxury Teaching Spa
Client Intake Form & Consent for Service
Advanced Academy Consent Forms
Attend SEEI
ESTHETICS LICENSURE COURSE
ADVANCED ESTHETICS ACADEMY
ESTHETICS EXCELLENCE CERTIFICATION PROGRAM
Certification Courses
Enroll
>
Student Housing
Enrollment Form
Student Aptitude Test
Financial Aid
>
CARES ACT
Continuing Education
DOWNLOADABLE GUIDES
About
Contact
Accreditation
Blog
COVID-19 Written Plan
>
Esthetics Student COVID Acknowledgement
Advanced Esthetics Student COVID Acknowledgement
Med Spa Consulting
Our Mission
Alumni Packages
Written Plans
Meeting Minutes
Instructor Guides
Meet Our Team
Alumni Spotlight
Careers
Completers & Employer Survey
Data Security Plan
Client intake form & consent for service
client intake form & consent for service
I understand that these are Estheticians IN TRAINING providing treatment today. As a learning environment, there is NO GUARANTEE that a private room will be available. I understand that Instructors, Spa Managers, and Student Helpers may be in and out of the room for observation, assistance, and safety. There is also NO GUARANTEE that the student requested will be the one providing my service.
I understand that SEEI has video monitoring services for use in the treatment rooms during learning time - and video monitoring services are NOT in use while outside clients are being treated at SEEI.
I understand that any services I have scheduled with Southeastern Esthetics Institute may carry a risk of injury. I recognize that as a result of these services, unpredictable side effects may occur, including, but not limited to, redness of the skin, inflammation, feelings of light headedness, irritation of the skin, blood pressure changes, and allergic reactions.
I understand that a medical evaluation is advisable before commencing any Southeastern Esthetics Institute service. I will continue to keep SEEI informed of any medical problems or change in my physical condition which may affect services that I have scheduled. I acknowledge that neither Southeastern Esthetics Institute, nor its employees are engaged in diagnosing or treating medical diseases or conditions. I expressly assume all risks to me associated with any service offered by Southeastern Esthetics Institute, and waive any claim which I might otherwise bring against SEEI, its officers, directors, shareholders, employees, or contractors as a result of injuries resulting from or relating to my participation in one or more services.
Southeastern Esthetics Institute shall not be responsible or liable for any article lost, stolen, or damaged in or about its facility.
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Indicates required field
I have read the statement above and agree to all terms.
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Yes
No
Name
*
First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Medications: Please list any medications or supplements you are currently taking.
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Medications: Please list any topical medications you are applying. i.e. Hydroquinone, Retin-A, Tazorac, Renova, Differin
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Do you have metal implants?
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Yes
No
Do you smoke?
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Yes
No
Please list any immune system disorders or physical illnesses.
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How would you describe your skin?
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Oily
Dry
Combination
Mature
Sun-Damaged
Acne Grades 1 & 2
Acne Grades 3 & 4
Rosacea/Broken Capillaries
Large Pore Size
Scarring and/or Acne Scarring
Discoloration
Uneven Skintone
Are you under medical supervision? If yes, explain.
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Females: Do you suffer from hormonal hair growth on upper lip, chin and/or chest?
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Yes
No
How often do you use sunscreen?
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Frequently
Occasionally
Rarely
Do you prefer extractions when you have a professional facial treatment?
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Yes
No
I consent to having microdermabrasion performed.
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Yes
No
I consent to having lash or brow tinting performed.
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Yes
No
Today's Date
*
Email
*
Phone Number
*
Date of Birth
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Emergency Contact & Phone Number
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Allergies: Please list any and all allergies.
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Are you pregnant or plan to become pregnant?
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Yes
No
Are you diabetic?
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Yes
No
Are you currently taking birth control?
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Yes
No
Please list any recent surgeries in the past five years.
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Have you or any member of your family had skin cancer?
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Yes
No
What is your skin tone?
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Very Fair
Fair
Medium
Medium-Olive
Dark
Very Dark
What is your daily skincare routine for day and evening?
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How often are you in the sun?
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Frequently
Occasionally
Rarely
How often do you receive facials, chemical peels, microdermabrasion, cosmetic laser treatments and/or cosmetic injections?
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I consent to having a chemical peel performed.
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Yes
No
I consent to having waxing procedures performed for the purposes of hair removal.
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Yes
No
I consent to having services performed in Advanced Clinics: Cosmetic Lasers, Microneedling, Micropigmentation, Dermaplaning or Medical Peels.
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Yes
No
Submit