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Personal Information

First name *

Last name *

Email *

Phone

Today's Date *

Month

Day

Year

Your Skin Concerns

Select all that apply

Skincare Routine

List your skincare routine & brands: (Cleanser, Toner, Hydrator, Moisturizer, Facial Oil, Exfoliants, Serums, etc.)

Upload a photo of your current home care products

Medical History

Do you have any of the following conditions? If yes, please select them.

Your Lifestyle

The lifestyle questions below help us better understand your day to day life so we can recommend treatments and products that suit you best. While optional, your answers help us determine whether a gentle or more advanced service is appropriate and safe.

What is your occupation:

What is your daily sun exposure?

Do you use sun protection (sunscreen, hats, protective clothing)?

Yes

No

Do you use tanning beds?

Yes

No

Do you drink more than 4 caffeinated beverages a day?

Yes

No

What is your alcohol consumption?

Your Skin History

Free Modality Selection

Which services are you most interested in from our FREE modality list? The free modality list is included in all of our signature facials and some of our specialty facials.

Client Consent Form

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

I hereby consent to and authorize SKIN ALCHEMY HI to perform the following procedure [FACIAL, ex. Microneedling, Jet Plasma, Custom Facial]:

I have voluntarily chosen to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me.

While it's impossible to list every potential risk and complication, I've been informed about potential benefits, risks, and complications. I understand that results are not guaranteed and may vary based on factors like age, skin condition, and lifestyle. Additional treatments for expected results may be needed, incurring extra costs.

I have read and understood the pre/post-treatment instructions on the SKIN ALCHEMY HI website. I understand how important it is to follow all my post-treatment care instructions. If I have additional questions or concerns regarding my treatment or suggested home post-treatment care, I will consult my esthetician immediately.

I have also, to the best of my knowledge, provided an accurate account of my medical history, including any known allergies and current use of prescription drugs or topical products.

I consent to the use of photographs for treatment documentation purposes, with all personal information kept confidential.

I have read and fully understand the consent agreement and all of my questions have been answered to my satisfaction. I hereby give my full consent to the procedure and subsequent treatments, releasing SKIN ALCHEMY HI and associates from any liability related to it. *

Photo & Video Release Form

This section asks for your consent to share photos/videos taken during your appointment. By checking yes or no, you either allow or do not allow the sharing of your photos/videos.

DISCLAIMER:

You do NOT need to accept these terms to book an appointment with Skin Alchemy HI. By accepting, you agree to allow Skin Alchemy HI to share videos and photos taken during your service. Skin Alchemy HI is VERY grateful for those who accept the terms, as it allows them to grow their business, but they completely understand that this may not be something clients are comfortable with. All minors will not have their photos shared, regardless of whether they are accepted.

Photo & Video Release *

Yes, I allow my photos/videos to be shared

No, I do not allow my photos/videos to be shared

Service Agreement & Policies

Last Updated: 01/24/2025

At Skin Alchemy HI, we do our best to provide a great experience while respecting your time and mine. These policies help ensure fairness for everyone. By booking an appointment, you agree to the following:

Cancellation and Rescheduling Policy:

At Skin Alchemy HI, deposits are required to secure your appointment. No-shows, cancellations, or reschedules within 48 hours of your appointment will result in a loss of your deposit.

Same-day cancellation will be considered a "no-show."

One reschedule is allowed with at least 48 hours' notice. A second reschedule will result in loss of your deposit.

No Show Policy:

No-shows will result in a cancellation fee for the booked service.

NO SHOWS WILL BE EXCUSED FOR THE FOLLOWING ONLY:

Jury Duty
Death in family
Military duties
Sickness
Injury

For any of the excusals above, please try to let me know at least 3 hours before your scheduled appointment time. A cancellation fee will be incurred for no-shows who do not inform Skin Alchemy HI before the appointment time.

Late Policy:

Arriving late to your appointment will affect your service time.

After 10 minutes, you will be considered a no-show. Please communicate your tardiness with me so I can prevent your appointment from being a no-show.

If I have open slots for a later time, I may be able to move your appointment!

If I do not have someone booked after you, I may be able to take you after passing the 10-minute threshold if you text me that you will be running late.

Please stay in contact with me! I try my best to take tardy appointments because I understand that traffic and life happens.

Please don't text and drive or speed. Just shoot me a text (808)272-9600 that you might be running late!

If you are considered a no-show and 10 minutes elapse without communication, you will be invoiced a cancellation fee if no deposit was made or your deposit will be forfeited.

Studio Policies / Disclaimers

Guests allowed! Bring a friend or friends!

Children are allowed, but bringing is not recommended. Please ensure they do not break or touch things, as it may be hazardous/dangerous for them. This is your time to relax, but I understand if you need to bring them along!

Skin Alchemy HI has the right to refuse or fire a client for any reason, regardless of follow-up appointments. In this case, follow-up appointments will be refunded.

Photos and videos taken during the appointment are for insurance purposes.

Refund Policy:

Payments will ONLY be refunded in the event a client is considered "Not an ideal candidate for the service" at the time of appointment, and what disqualifies them as a client is not listed on the Skin Alchemy HI website in pre-care instructions.

Refunds will only be given for cancellations made within the 48 hr window and excused no-shows if full payment was made online.

If you are unhappy with your service, please text or email me! Because services were rendered, all services are nonrefundable. I will do my best to offer a solution if you are not satisfied with your treatment.

I have read and completed the consultation questionnaire truthfully. I understand that withholding information or providing inaccurate details about my medical history, allergies, medications, and skincare routines may lead to contraindications or adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information. *

By signing below, I hereby acknowledge that I have completely read and fully understand the photo and video release agreement.

By signing below, you confirm that you have read and agree to Skin Alchemy HI policies. *

Signature

Signature *

By signing (drawing or typing your name), you are providing your electronic signature

Parent/Guardian Signature (If client is a minor)

Consultation Form