Online Intake Form

Please complete this form once per year. It helps us provide the safest, most personalized care.

Your Information

Full Name *BirthdayEmail *Phone NumberAddressOccupationReason for booking today?

How did you hear about us?

Service Interest

Your Health

Are you experiencing any of the following? (check all that apply)

Any other health conditions not listed?List any medications, supplements, or vitamins you take regularlyAre you using any topical prescriptions?Do you wear contact lenses?

Do you have metal implants, a pacemaker, or body piercings?

Do you have any allergies (foods, products, animals, etc.)?

Skin Care

What skin concerns do you currently have?

Describe your specific skin concerns or challengesWhat skincare products are you currently using?Any chemical peels, microdermabrasion, or resurfacing in the last month?

Any dermaplaning, microneedling, Botox, fillers, or advanced treatments in the last month?

Have you ever used or are you currently using Accutane®?

COVID-19 Consent & Liability Waiver

I acknowledge the contagious nature of COVID-19 and that Dani's Skin Haus cannot guarantee I will not become infected. Because skincare services involve close physical proximity over an extended period, there may be an elevated risk of disease transmission. By checking below, I acknowledge the risks involved and consent to receive services.

I knowingly and willingly consent to services during the COVID-19 pandemic. *

Photo & Video Release

Before-and-after pictures may be taken to track your skin's progress. Do you give permission for Dani's Skin Haus to post photos/videos of your services on its website and social media?

Cancellation & Rescheduling Policy

Should you need to cancel or reschedule, please note:

A 24-hour notice is required for any single service appointment.
A 48-hour notice is required for spa packages or multiple services.
Deposits can be transferred if notice is provided within the above timeframes.
A 10-minute grace period is provided. After 10 minutes your service will be rescheduled and a fee applies.

Fees: Appointments not cancelled/rescheduled within the timeframe are assessed a fee of 25% for in-studio and 50% of the service cost for mobile appointments, in addition to your deposit. Same-day cancellations are assessed a fee equal to the full value of the service booked.

I have read and agree to the cancellation & rescheduling policy. *

Release & Signature

I confirm the answers I have given are correct and that I have not withheld any relevant information. I understand these services are for skin health and wellness, and that I participate at my own risk. To the fullest extent permitted by law, I agree to release, indemnify, and hold harmless Dani's Skin Haus and its affiliates, owners, employees, and agents from any and all claims, liability, damages, or costs arising from the services rendered.

I have read and fully understand the above, and I accept the risks. *Signature (type your full name) *Date *

Your information is kept confidential and used only to provide safe, personalized service.