SKINCARE CONSENT FORM

DATE*

Date

NAME*

First NameLast Name

DATE OF BIRTH*

Date

EMAIL*

example@example.com

ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PHONE NUMBER*

Area CodePhone Number

HOW DID YOU HEAR ABOUT US?*

If referred, by who?

Are you currently under the care of a physician?*

YESNO

Have you experiences any of these health conditions in the past or present?*

Any known allergies?*

List medications/supplements you are currently taking.*

Have you ever received any botox or fillers? if so, where and when? *

Have you ever experiences claustrophobia?*

YESNO

Please rate your stress level*

LowMediumHighNone

What are your skin concerns?*

What are your skin goals?*

What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)

Please upload a clear, makeup free picture/video of your skin.*

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What skincare products do you use on a daily basis? Please be specific.

AM Skincare Products*

PM Skincare Products*

Do you experience any breakouts or acne?*

YESNO

Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO

Have you received any of these facial hair removal services in the last 7 days?*

Waxing/sugaringThreadingLaser/ElectrolysisNone

Do you currently use:*

AccutaneRetin-APrescribed topical creamNone

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:*

Please check the box to acknowledge:*

Discontinue the use of exfoliants and retinols 3-7 days before your appointmentIf you are on a prescription retinoid by a dermatologist, you need to discontinue use two weeks prior to your chemical peel

Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO

Do you?*

Are you taking birth control?*

YESNO

Are you pregnant or breast-feeding?*

YESNO

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Glow Treatment Studio and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

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SKINCARE CONSENT FORM

Your Medical History

Your Skin

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