Facial Waiver

Facial Waiver
Name

First Name Last Name
Phone Number

Area Code Phone Number
What type of skin do you have? *

Normal Oily Dry Combination
What areas of concern do you have regarding your skin? *

Breakouts/Acne Blackheads/Whiteheads Uneven Skin Tone Sun Damaged Excessive Oil/Shine Wrinkles/Fine Lines Dull/ Dry Skin Rosacea Broken Capillaries Redness/Ruddiness Dehydrated Sun, Liver, Brown Spots
Have you been under the care of a Dermatologist within the past year? *
If Yes please list below.
List Dermatologist
Have you ever had an allergic reaction to any of the following?

Cosmetics Medicine Food Animals Sunscreen Drugs Iodine Pollen AHAs Fragrance Shellfish Latex
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retino/ Vitamin A derivative products? *
Have you received any of the following in the last 6 months?

Botox Restylane Collagen Injections
By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatment and agree that I do not have conditions that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury and or damages incurred due to any mispresentation of my health history.
Signature

Clear
Date

Month Day Year
Date
Should be Empty: