Boss Beauty Inc. Facial 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

Are you currently under the care of a dermatologist?*

YESNO

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

Any known allergies?*

List medications /supplements you are currently taking.*

Please list any dietary restrictions.

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

Please answer what parts of the face and when.

Are you claustrophobic?*

YESNO

Please rate your stress level*

LowMediumHighNone

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)

What are your skin concerns? Check all that apply.*

Please share with me anything else about your skin concerns.

What is your current relationship with skincare?*

I love trying different products all the time.I have a routine that works for me.I don’t feel like my products are working for me.I dont know much about skincare.

Please list all skincare products and brands you are currently using. (Cleansers, Exfoliants, Toners, Serums, Moisturizers, Oils, Masks, SPF, Tools, etc.)*

Please be specific.

How often are you using your skincare products?*

Morning OnlyNight OnlyMorning and NightNone

Do you experience routine 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 specify which product or type, if you answered YES to the question above.

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

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

Do you wear makeup regularly?*

YesNo

Do you play sports or workout regularly?*

YesNo

Do you wear sunscreen regularly? (SPF in makeup does not count)*

YesNo

Do you?*

Are there any treatments you’d like more info on?

Are you taking birth control?

YESNO

Are you pregnant, breast-feeding or trying to become pregnant?

YESNO

Are you currently menstruating or will be the week of your appointment?

YESNO

I give Michelle Nguyen and Boss Beauty by Michelle Nguyen LLC permission to take photo and/or video of me during my service to use l between treatments. I acknowledge that these photos and videos of me may be posted onto social media platforms, including but not limited to Instagram. I give Boss Beauty, including Michelle Nguyen my full consent for the usage of photos and videos of me.

I agree.

I acknowledge that I must adhere to Boss Beauty's (Michelle Nguyen) policies. I understand that cancellations must be done with at least 48 hours notice. I understand that after 10 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy. Deposits are non-refundable. If I pre-book an appointment, with no deposit, and cancel less than 48 hours in advance or have to reschedule, I will be responsible for a rescheduling and cancellation fee.

Please discontinue the use of exfoliants 2-3 days before our appointment. Retinol prodcuts must be discontinued at least 7 days before your appointment. If I should need to be rescheduled due to this, I will be responsible for the rebooking fee.

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 sunscreen everyday, and reapply every 2 hours, 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 Boss Beauty, including Michelle Nguyen and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Boss Beauty, including Michelle Nguyen from liability and assume full responsibility thereof.

Signature

Boss Beauty by Michelle Nguyen LLC

Your Medical History

Your Skin

Female Clients