5.1 Client Intake, Health History, Informed Consent, and Documentation

Why intake is scored before you touch the skin

On the current PSI National Esthetician Theory examination that Georgia has used since 11 August 2025, Client Consultation and Skin Analysis is Domain 2 at 19 percent. That is roughly 14 of 75 scored items in a 90-minute, 75 scored plus 10 experimental sitting. Domain 2.A names client intake and consent form procedures to determine possible contraindications as its first bullet. Independent OpenExamPrep teaching for Georgia candidates treats the first ten minutes in the room as the moment you decide whether a cosmetic service is even allowed.

Georgia school training matches that emphasis with clock hours, not slogans. Ga. Comp. R. & Regs. r. 240-16-.02 requires 1,000 hours over at least nine months: 250 Level 1 theory plus 750 Level 2 service-application hours. Students need a 75 percent Level 1 score before clinic-floor work on live patrons. Level 1 is 150 hours Professional Practices, 20 hours Professional Ethics, and 80 hours Business Practices. The 20-hour ethics block is professional attitude and personal image. The paperwork you are about to memorize sits in the 80-hour Business Practices list: State Board rules and laws, salon development, insurance, client records, confidential ethics, medical record keeping, resume, and the job interview.

Level 2 then repeats the skill with a live person in the chair. Sciences is 320 service-application hours and expressly includes medical terminology, medical charting, patient psychology, customer service, and advanced skin analysis/diseases. Facials total 115 hours; machine facials (30 hours / 30 applications) must include client consultation and skin analysis, cleansing, manipulations, and toning. Make-up includes client consultation and skin analysis at 20 hours / 40 applications. Rule 240-16-.03 credits one client consultation and skin analysis at 30 minutes per application. If a student in a Marietta school logs a five-minute greeting as a full consultation, the credit file is wrong.

This OpenExamPrep chapter is independent study material covering those Georgia curriculum topics and the Domain 2 consultation tasks. It is not a Board form packet and it does not claim official approval, review, or partnership with PSI or the Georgia State Board of Cosmetology and Barbers.

Three documents, three jobs

Do not collapse every piece of paper into one “release.” Exam stems punish that shortcut.

| Document | What it captures | What it is not | |---|---| | Health history / intake | Identity, emergency contact, medical and skin history, medications, allergies, recent procedures, sun and lifestyle, home care, goals | A diagnosis, a treatment plan, or permission to work on broken skin | | Informed consent | The named cosmetic service, foreseeable reactions, aftercare, the client's right to stop, dated signatures | A waiver that overrides Rule 240-4-.02 intact-healthy-skin signage or O.C.G.A. § 43-10-1(8) | | Service / treatment chart | Date, observations, products and devices used, modifications, home care, next visit | A dermatology record that names a disease you are not licensed to diagnose |

Update the intake every visit. A Buckhead client who was “on no pills” in March may start doxycycline in June. A chart that is six months stale is a safety failure even if the original form was perfect.

What belongs on the intake

Ask, listen, and write. Open questions (“What has changed with your skin or your medicines since last time?”) beat a silent form shove.

• Identity and logistics: name, date of birth, emergency contact, occupation (outdoor work, food service, healthcare night shift), preferred contact method.
• Skin and procedure history: cold sores, keloid tendency, eczema or psoriasis flares, recent injectables, laser or IPL (those devices are outside the esthetician licence — see Chapter 11), recent peels or waxing, last professional facial.
• Medications and topicals: prescriptions, over-the-counter pills, herbals, and every leave-on acid or retinoid at home. Georgia has not published a Board drug list. You still screen the classes that standard esthetics texts flag, because Domain 2.A is about possible contraindications, not about reciting a SOS PDF.
• Allergies: latex, fragrance, preservatives, aspirin/salicylates, iodine, nuts, shellfish extracts, adhesives, PPD-type dyes if tint is on the menu.
• Pregnancy, nursing, or trying to conceive: not a Georgia statutory ban on every facial, but a reason to drop electrical modalities and aggressive chemistry unless a physician has cleared a specific cosmetic plan in writing.
• Goals: hydration, congestion, makeup event, hair removal. Goals never beat safety.

Medication red flags (textbook teaching, not a Georgia Board table)

The Board has not issued a Georgia-specific wait-time chart for named drugs. Product labels, prescribers, and standard esthetics textbooks still expect you to pause services that wound or thin the barrier.

| Class (examples commonly taught) | Why the consultation cares | Typical textbook handling | |---|---| | Oral isotretinoin (Accutane and generics) | Epidermis thins, healing slows, wax and peels can strip living tissue | Commonly taught wait of at least 6 months after the last dose before waxing, chemical peels, or aggressive mechanical exfoliation; longer if a physician directs | | Topical retinoids (tretinoin, adapalene, tazarotene, retinol at leave-on strength) | Stratum corneum thins; wax lifts epidermis; acids penetrate faster | Commonly taught 48–72 hour hold before waxing or chemical/mechanical exfoliation | | Anticoagulants / antiplatelets (warfarin, heparin, clopidogrel, daily aspirin, DOACs) | Bruising and prolonged bleeding with extractions, vacuum, or wax | Lighten or skip extractions and deep friction; do not “clear the T-zone” as a badge of thoroughness | | Photosensitizers (tetracyclines such as doxycycline, some diuretics such as hydrochlorothiazide, St. John's wort, certain NSAIDs) | Exaggerated burn and pigment from sun or aggressive exfoliation | Extra photoprotection counseling; scale back peels and heat; this is not a Georgia Board laser protocol |

If the intake is blank on medicines, ask again out loud. Clients forget “just a pimple cream from dermatology.” That cream is often tretinoin.

Informed consent in a cosmetic room

Consent is a conversation you can prove. It is not a stack of unread initials.

1. Name the service in ordinary language (spa facial with steam and a clay mask; hard-wax lip; lash tint).
2. Name foreseeable reactions (temporary redness, tightness, rare allergy, bruising from extractions).
3. Name what you will not do (diagnose a mole, treat an open wound, use a laser on the esthetician licence).
4. Confirm the client had a chance to ask questions and may stop the service.
5. Date and sign — client and licensee. For a minor, a parent or guardian signs; Georgia Chapter 240 does not publish a spa-specific minor form, so follow school or facility policy and still obtain guardian consent.

Consent does not authorize work on non-intact skin. Rule 240-4-.02 required consumer signage states that all cosmetology services shall only be performed on intact, healthy scalp, skin, and nails. Initials on a waiver do not repeal that sentence.

Confidential ethics and medical charting

Confidential ethics and medical record keeping are named Level 1 Business Practices topics. Medical charting returns in Level 2 Sciences. Georgia Chapter 240 does not publish a required SOAP template or a statewide retention year for spa charts. Teach this professional standard anyway:

• Store paper charts so other patrons cannot read them. Do not leave a health history on the Midtown reception desk beside the retail tester stand.
• Do not discuss a client's medicines, pregnancy, or lesions in the hallway where the next guest is waiting.
• Chart observations (“0.6 cm dark, irregular patch at the right temple; client reports it darkened this year”) not diagnoses (“melanoma”).
• Standard textbooks use SOAP (Subjective, Objective, Assessment, Plan) as a charting habit. If your school uses SOAP, keep Assessment as an esthetic evaluation of tolerance and goals, not a medical disease name.
• Follow the facility's retention policy and your liability carrier. Do not invent a “Georgia 7-year spa HIPAA rule” on the theory exam; the curriculum names confidentiality, not a published retention number.

Georgia spa scenario: the incomplete Buckhead intake

A 29-year-old client books a lip wax and a “glow peel” at a licensed spa in Buckhead. The online form shows no oral medicines. Under home care she listed “night cream from my dermatologist.” In the room she says she finished a five-month oral isotretinoin course eight weeks ago and started tretinoin 0.05 percent five nights ago. She has a wedding in Savannah in four days and wants both services today.

You do not diagnose acne. You do not argue about her dermatologist. You decline waxing and the chemical peel because standard teaching treats recent oral isotretinoin as a hard stop for those services, and last night's tretinoin is a second, independent reason to hold wax and acid. You offer a gentle cleanse, hydrating mask, and brow tweezing only if the skin is intact, document the medicines and the declined services, and give a return condition (textbook six months after the last oral isotretinoin dose for wax/peel unless her prescriber writes a different cosmetic plan). Consent for a hydrating facial is a new, accurate consent — not the peel consent she already signed online.

Traps

• Putting client records in the 20-hour Professional Ethics bucket; the rule puts them in Business Practices.
• Treating a signed waiver as permission to work on eczema cracks or a cold sore.
• Skipping the verbal medicine question because the form is “done.”
• Charting a disease name to sound clinical.
• Crediting a hallway greeting as a 30-minute consultation/analysis application under Rule 240-16-.03.