Facial & Skin Care

Facial & Skin Care

Client Consultation Form
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Please fill out this form before your appointment. Your answers will better help me to meet your needs and ensure that you have a happy and satisfying experience.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Google SearchFacebookInstagramReferralReferred by?
YesNo
If yes, when was that?
AcneScarsWrinkles/fine linesAge spotsAcne scarringEnlarged poresDeep WrinklesUneven skin toneDark eye circlesHyperpigmentationBlackheads/ whiteheadsDull/dry skinDehydratedSun damagedRosacea
What would you like to achieve from your treatment today?
Do you have any special skin problems or concerns pertaining to your face or body?
If yes, please specify
Please let me know what your current skin regimen is, including your morning and Night time routine. Provide brand names and include cleanser, exfoliant, toner, moisturizer, sunscreen and any masks that you might be using.
NormalDryOilyCombinationSensitiveAcneVery sensitiveMature
Glycolic AcidAcetic AcidAny exfoliating scrubsAny hydroxy acid productsVitamin A derivatives (i.e. retinol)Retin-ARenova
Ingrown hairHyperpigmentationScarringBruisingBumps/ HivesRedness
MicrodermabrasionChemical PeelLash/ Brow TintMicroneedlingFacial WaxingLaser ResurfacingBotox, Restylane or Collagen InjectionsType option 2Type option 3Type option 4
CosmeticsMedicineFragrancePollenFoodHydroxy AcidsAnimalsSunscreenOther
Your Health

This information is to ensure we carry out the appropriate treatments for you, taking into consideration any medical conditions which might have treatment contraindications.
PregnancyMenopauseHeart ConditionHigh Blood PressureRosaceaEczemaAsthmaVaricose VeinsWater RetentionDiabetesEpilepsyPsoriasisDermatitisSkin Cancer
Any other medical conditions?
Are you taking medications?
Do you smoke
Do you follow a restricted diet?
Within the last 9 months, have you undergone any surgery?
Within the last year, have you been under a dermatologist or other physicians care?
How would you describe your stress levels 1-10 (1=low, 10=high)
Male Clients Only
ElectricWet Shave
Do you experience irritation from shaving?
Do you experience ingrown hairs?
Policies
Cancellation Policy

No Call/No Show: If you no call/ no show your card on file will be charged 100% of your service
Late Arrival: If you are 15 minutes late to an appointment 30 minutes or less your appointment will be canceled and charged 50%.
Rescheduling: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% charge of the scheduled appointment. All appointments will be required to have a credit card on file. Your card will not be charged unless you cancel less than 24 hours or no show.

Sick Policy

Please always reschedule if you or your immediate family is ill or has been in the last 48 hours. I work very closely with clients and take every precaution to keep my space safe and sanitary.

Informed Consent
- I acknowledge that side effects can occur and I fully accept the risk.
- I understand that my technician will take every precaution to minimize or eliminate negative reactions as much as possible.
- I will consult my technician first should I have any complications after receiving my treatment. I have been given the opportunity to ask questions and any questions have been answered to my satisfaction.
- I have read the information and recorded my medical history accurately with all pertinent information.
- For future services, I agree to inform my technician of any changes in my medical status and/or the above information.
- I understand spa services are not considered medical treatment, and as such, the technician cannot prescribe treatment of pharmaceuticals.
- I agree that my technician may determine that it is unsafe for me to continue a facial session due to health-related concerns. In this event, I may be required to provide a medical release form from my physician prior to continuing treatment.
By typing your name below you agree to the terms and conditions listed above.

First NameLast Name
Date

MonthDayYear
Date
PHOTO/VIDEO CONSENT FORM
I, hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded in audio or videotape without payment or any other consideration.
I understand that my image may be edited, copied, exhibited, published, or distributed.
Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.
By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the internet or in the public educational setting.
Name

First NameLast Name
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Facial & Skin Care

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Your Health

Male Clients Only

Policies

PHOTO/VIDEO CONSENT FORM