Facial Consent Form

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.
Heading

General Information
Name

First Name Last Name
Birth Date

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Do you have any skin concerns today?
Medical History
Do you have any allergies?
Have you ever had any allergic reactions to any of the following?

Algae Animals Asprin Cosmetics Dairy Essential Oils Food Latex Medicine Niacin Nuts Salicylic Acid Shellfish Sulfer Sunscreen None
Have you had any of these health conditions in the past or present (Please check all that apply)

Anemia Any Active Infections Asthema Arthritis Blood Clotting Disorders Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Herpes Hepatitis HIV/AIDS Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Kidney Disease Liver Disease Sleep Apnea Skin Cancer Use of C Pap Machine thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema Keloid Scarring Skin Disease/Skin Lesions Metal Bone Pins, Plates or Pacemaker None
Other Illnesses ?
Please list any surgeries, including plastic surgery.
Please list your current oral and topical medications
Are you pregnant or nursing? If pregnant list how many weeks.
Are you or have you been on Accutane within the past 6 months?

Yes No
Have you used Retin-A, Renova, AHA or Retinol derivative products within past 5 days?

Yes No
Have you had Botox or Dermal Fillers?
What areas of concern do you have regarding your skin?

Blackheads/Whiteheads Breakouts/Acne Broken Capilaries Congestion Deep Wrinkles Fine Lines Discoloration Dull/Dry Skin Oily Skin Other
Healthy & Unhealthy Habits
Does your skin get red or irritated easily?

Yes No
Do you wear contact lenses?

Yes No
Are you Claustrophobic?

Yes No
Alcohol Consumption

I don't drink 1-2 Glasses/wk 3-4 Glasses/wk 5+ Glasses/wk
Do you smoke?

Yes No
Please list any skincare products that you area currently using.
Please ready ALL the following statements carefully and indicate your understanding and acceptance:

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 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 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 understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness 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 a member of the Shear Luxury Beauty Industries llc staff. 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 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 have not had a peel treatment of any kind within 14 days of my treatment at Skin Facial Bar llc. I understand I cannot have another treatment until recommended by a licensed professional at Skin Facial Bar llc. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by the Shear Luxury Beauty Industries LLC staff. PHOTOGRAPHS: I give permission for photographs to be used by the Shear Luxury Beauty Industries llc staff for monitoring my treatment progress. 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 Shear Luxury Beauty Industries llc of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments. 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 Shear Luxury Beauty Industries llc and any of its employees 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. By my electronic signature below, I give consent to receive treatments at Shear Luxury Beauty Industries 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 Shear Luxury Beauty Industries, LLC for any services rendered.
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Facial Consent Form

Heading

Medical History

Healthy & Unhealthy Habits