Ever Be Beauty Facial Consent Form

Ever Be Beauty Facial Consent Form

FACIAL CONSENT FORM may include: enzymes, acid peels, dermabrasion, dermaplaning, extractions, microcurrent, galvanic, high frequency, ultrasonic, LED Light Therapy and other treatment modalities as necessary.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Your Medical History
Have you experienced any of these health conditions in the past or present?

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpilepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigrainesNoneOther
Any known allergies?*

AspirinLatexFruitsShellfishLidocaineFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther
List medications/supplements you are currently taking.
Are you or have you been on Accutane within the past 6 months?*

YESNO
Have you ever received any botox or fillers? if so, where and when?
Please rate your stress level

LowMediumHighNone
Are you Claustrophobic?*

YESNO
Your Skin
What areas of concern do you have regarding your skin? Please be specific in the tab named, "other" if your concern is not listed.

Blackheads/WhiteheadsBreakouts/AcneCongestionDeep WrinklesFine LinesDiscolorationDull/DrynessOilyOther
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 skin care products do you use on a daily basis?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
Please list any skincare products that you are currently using:
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Have you been diagnosed with eczema, psoriasis or rosacea?

YESNO
Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5 days?:

YESNO
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
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 contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning bedsConsume Alcohol
Females Clients
Are you taking birth control?

YESNO
Are you pregnant or breast-feeding?

YESNO
Please read ALL of the following statements carefully and indicate your understanding and acceptance:
1. I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, dermabrasion, dermaplaning, extractions, microcurrent, galvanic, high frequency, ultrasonic, LED Light Therapy and other treatment modalities as necessary.

I agree
2. I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.

I agree
3. I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.

I agree
4. I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness

I agree
5. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Ever Be Beauty

I agree
6. I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory.

I agree
7. I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior.

I agree
8. I have not had a peel treatment of any kind within 14 days of my treatment at Ever Be Beauty llc. I understand I cannot have another treatment until recommended by a licensed professional at Ever Be Beauty llc. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by the Esthetician at Ever Be Beauty llc.

I agree
9. PHOTOGRAPHS: I give permission for photographs to be used by the Ever Be Beauty llc staff for monitoring my treatment progress.

I agree
10. Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Skin Facial Bar llc of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I agree
11. I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release Ever Be Beauty llc against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.

I agree
12. By my electronic signature below, I give consent to receive treatments at Ever Be Beauty, LLC and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or Ever Be Beauty, LLC for any services rendered.

I agree
Signature
Should be Empty:

Ever Be Beauty Facial Consent Form

Your Medical History

Your Skin

Females Clients