Facial Consent Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Facebook
Google
Instagram
Family
Friend
Medical Patient
Walk in
Other
Have you had any waxing procedure in the past 72 hours?
*
Yes
No
Do you use any Retin-A, Renova, Adapalene, or any other prescription skin products?
*
Yes
No
Have you had sun exposure in the past 48 hours?
*
Yes
No
Do you have any sinus issues, history of cold sores or fever blisters?
*
Yes
No
Have you ever or do you experience skin sensitivity?
*
Yes
No
Have you had a peel, microdermabrasion, laser or light therapy in the past month?
*
Yes
No
Are you currently using any products that contain glycolic acid, lactic acid, hydroxy acid?have any sinus issues, history of cold sores or fever blisters?
*
Yes
No
How do you like your treatment enviroment?
Quiet, no talking, dark etc
Current Medications
*
Medical History/ Recent Procedures
*
What skin brand/ range care products are you currently using?
What brand/ range body products are you currently using?
Do you have any allergies? If so, please specify
*
Including foods/plants/essential oils/reactions to aspirin
Signature
*
Submit
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