ILLUME SKIN SPA
FACIAL/ADVANCED FACIAL Consent Form
Personal Information
Date
-
Month
-
Day
Year
Date Picker Icon
Full Name
*
First Name
Last Name
Birth Date
*
Address
*
Street Address
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
E-mail
*
How did you hear about us
*
Medical Information:
Reason for visit
Have you had cosmetic surgery
*
Yes
No
Type of surgery
What type of skin care products do you use?
Cleanser
*
Yes
No
Day Moisturizer
*
Yes
No
Night Moisturizer
*
Yes
No
Alpha Hydroxy Acid
*
Yes
No
SPF
*
Yes
No
Please list the name of all skin care products that you are currently using:
Have you taken Accutane for acne in the past 12 months:
*
Yes
No
Do you have Eczema, Seborrhea, or Rosacea?
*
Yes
No
Where
Are there any medical problems we should be aware of (HIV, AIDS)?
*
Yes
No
If so, please list
Do you use Retin-A or Renova
*
Yes
No
Do you use oral or topical antibiotics
*
Yes
No
Cold Sores
*
Yes
No
Carcinoma
*
Yes
No
Diabetes
*
Yes
No
Acne
*
Yes
No
Latex Allergies
*
Yes
No
Blood Thinners
*
Yes
No
Heart Condition
*
Yes
No
Hepatitis
*
Yes
No
High Blood Pressure
*
Yes
No
Tuberculosis
*
Yes
No
Keloid Scars
*
Yes
No
Pacemaker
*
Yes
No
What is your skin complexion?
Light
Medium
Olive
Dark
Is your skin
Dry
Oily
Combination
What do you want to improve most about your skin?
I do hereby agree to the following. I am allowing ILLUME SKIN SPA to take photos of my treatment and/or treated areas to be used to the purpose of monitoring my progress/use on ILLUME SKIN SPA website my identity will remain anonymous.
*
Full Name
Children under 16 are not allowed on the premises. In the occurrence of breaking this policy, your appointment will be rescheduled or canceled and a last-minute cancellation fee of $50 will be applied.
*
I understand and agree to follow this policy.
Cancellation Policy
*
I AGREE THAT A 48 HOUR NOTIFICATION IS REQUIRED TO AVOID A $50 CANCELLATION FEE OR A $50 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
Signature
*
Submit
Should be Empty: