Facial Consent Form

Facial Consent Form
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Phone Number

Area CodePhone Number
Do you regularly see a Dermatologist?
Are you prescribed any medication for your skin? (oral or topical)
If so, please list here:
Do you have a pacemaker or metal implants?
Are you actively receiving treatment for Chemotherapy or Radiation?
Are you allergic to aspirin?
Please list ANY other allergies: (cosmetics, food, sunscreens, iodine, pollen, fragrance, shellfish, latex, etc.)
Please list ANY medical conditions: (Cancer, Diabetes, Immune Disorder, any Heart Condition, High Blood Pressure, Epilepsy, etc.)
Please list ANY medications you are currently taking:
Any recent surgery or injury?
Have you had facials or peels before?
Would you like to get facials more regularly?
Do you go tanning? (laying outside or in a tanning salon)
Do you wear sunscreen?
Do you smoke?
Do you drink enough water daily?
Do you follow a healthy diet and exercise?
List all of the facial products you are currently using: (cleanser, moisturizers, serums, toners, etc)
Women only:
Are you taking any hormonal contraceptive?
Are you pregnant or breastfeeding?
Are you menopausal or post menopausal?
Are you undergoing any hormonal replacement therapy?
Men only:
What is your shaving routine?
Do you experience irritation from shaving?
Are you experiencing any of the following today:
Check all that apply:
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 Bliss Studio & Spa/ Michaela Frechette from liability and assume full responsibility thereof.
CLIENT NOTES
Signature
Date

MonthDayYear
Date
Should be Empty:

Facial Consent Form

Women only:

Men only:

Are you experiencing any of the following today: