Skin Consent Form

Date

Name

Date of Birth

Date

Address

Home Phone

Business Phone

Cell Phone

E mail address

example@example.com

Single

No Yes Married:No

No

Yes

If yes, anniversary date

Date

Employer

NoYes Does your job require that you work outdoors?

Employer

Occupation

Referred by

What would you like to achieve from your treatment today?

Your Skin Care

No 1 Have you ever had a facial treatment before?

1 Have you ever had a facial treatment before?

NoYes Yes No Yes No Yes, when? 2 Have you ever had a body spa treatment before? Massage: Salt glow: Seaweed wrap: NoYes Yes No Body scrub: Other:

2) Have you ever had a body spa treatment before? Massage: Salt glow: Seaweed wrap:

Yes, when?

NoYes

No Yes, when?

Other

3) Which of the following best describes your skin type? (Please circle one type number)

III

Creamy complexion Light Complexion Light/Matte Complexion Matte Complexion Brown Complexion Black Complexion

Always burns easily, never tans Always burns, tans slightly Burns moderately, tans gradually Seldom burns, always tans well Rarely burns, deep tan Never burns, deeply pigmented

Yes No 4 Do you have any special skin problems or concerns pertaining to your face or body?

Always burns easily, never tans Always burns, tans slightly Burns moderately, tans gradually Seldom burns, always tans well Rarely burns, deep tan Never burns, deeply pigmented

No Yes

specify

Yes

5 Have you ever had chemical peels, laser or microdermabrasion? No 6 Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? Yes In the last month? No Yes

Associated Skin Care Professionals

Client Consultation - continued

7 Have you used any of these products in the last 3 months?

NoYes

No

8 Have you used an acne medication?

NoYes, when?

Yes, when?

Which drug?

Soap

Shower Gels

Toner

Body Lotions

Mask

Sunscreen

Eye Product

SPF

Cleanser

Night Moisturizer/Cream

Day Moisturizer

Other

Exfoliator

Scrubs

Makeup Products

9 What skin care products are you currently using? List brand where known

10 Have you recently used any self-tanning lotions, creams or treatments?NoYes, specify:

10) Have you recently used any self-tanning lotions, creams or treatments?NoYes, specify:

Yes, specify

11Have you used any of the following hair removal methods in the past six weeks?

No Yes, circle all that apply.

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

12) What areas of concern do you have regarding your: Skin: (Please check any that apply and explain)

Breakouts/acne

Uneven skin tone Blackheads/whiteheads Excessive oil/shine Rosacea Broken capillaries

Uneven skin tone

Sun damage Wrinkles/fine lines Dull/dry skin Flaky skin Dehydrated

Sun spot/liver spot/brown spot

Other

puffiness

dark circles Other

Other: dehydratedcracked/chapped lips 13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain) If yes, please explain:

Other

If yes, please explain

Cosmetics

Fragrance Shellfish Other: dehydratedcracked/chapped lips 13 Have you ever had an allergic reaction to any of the following? Please check any that apply and explain If yes, please explain: Latex Animals

Other

Associated Skin Care Professionals

Client Consultation- - continued

14 What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?

16 Have you had any recent tanning bed or sun exposure that changed the color of your skin?

No Yes

specify

NoYes 17 Have you experienced Botox, Restylane or Collagen injections?

specify

Yes No Female Clients Only: 18 Are you taking oral contraceptives?

specify

19 Any recent changes to or from your contraceptive treatment? 16 Have you had any recent tanning bed or sun exposure that changed the color of your skin?

specify

19 Any recent changes to or from your contraceptive treatment?

NoYesIngrown hairs? NoYes 25 Do you experience irritation from shaving? Yes No

If so, what and when

NoYes 20 Are you pregnant or trying to become pregnant?

If so, what and when

20 Are you pregnant or trying to become pregnant?

No Yes 21 Are you lactating?

21 Are you lactating?

NoYes 22 Any menopause problems?

specify

Yes No 23 Are you undergoing any hormone replacement therapy?

specify

Electric Male Clients Only: 24 What is your current shaving system? Wet shave

specify

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Yes No Future Appointments/Contact: May call you at your home, work or cell phone number to confirm future appointments?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: May | call you at your home, work or cell phone number to confirm future appointments?

NoYes May contact you via mail/email about future promotions and news?

May | contact you via mail/email about future promotions and news?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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 | receive here are voluntary and | release this institution and/or skin care profes- sional from liability and assume full responsibility thereof.

Client Signature

Clear

Date

IV V VI