FACIAL CONSENT FORM

FACIAL CONSENT FORM

Thank you for Choosing EN Signature Brows and Beauty Studio for your services. We love to give our clients the best quality service. Please fill out the form below.
Name

First NameLast Name
Occupation
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
Occupation.
Does your job require you to work outside?
Select One
What would you like to achieve from your treatment today?
What is your skincare routine? Tell me about the products you use and the frequency of application/usage.
Have you ever had a facial treatment?
If "Yes" when?
Date
Which of the following best describes your skin type?
Do you have any skin conditions pertaining to your face or body?
If "Yes" please explain.
Have you ever had chemical peels, laser or microdermabrasion?
If so, When?
Have you had any Botox, Restylane, or Collagen injections?
If so, When?
Do you currently use Rentin-A, Adapalene Hydroxyl Acid or Rentinol/vitamin A derivative products?
Have your used Rentin-A, Adapalene Hydroxyl Acid or Rentinol/vitamin A derivative products within the last 3 months?
Do you currently or within the last 3 months take any other acne medication?
If so, please specify which drug and last dosage:
Have you recently used any self-tanning lotions, creams, or treatments?
If so, When?
Have you used any of the following hair removal methods in the past 6 weeks?
What areas of concern do you have regarding your skin?Please check all that apply:

Other
Any allergies we should be aware of?
I understand that with treatment,certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.
Please select
I give Elizaveta Neginskaya permission to take, publish and reproduce photographs of me, my face, and/or my eye area, both before and/or after the procedure for advertising and other purposes
Please select
Female Clients Only:
Are you currently taking oral contraceptives
If "Yes", Please specify
Any recent changes to or from your contraceptive treatment?
If "Yes", Please explain
Are you Pregnant?
If "Yes", Please specify
Are you lactating?
If "Yes", Please explain
Any Menopause problems?
If "Yes", Please specify
Are you undergoing any hormone replacement therapy?
If "Yes", Please specify
Male Clients only:
What is your current shaving system? Please check
Do you experience irritation from shaving?
Ingrown Hairs?
I am 18 years or older
I am not 18 years old. This is my parental and/or guardians signature for consent to this service. By signing below you are full aware of all the possible risks.
Print Parental/Guardians name:
first and last name
REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or for another individual are absolutely non-refundable.This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.
I give my consent to Elizaveta Neginskaya for facial services. My signature below acknowledges that I have not knowingly withheld or falsified my above personal information and I will adhere to all the aforementioned statements that I have initialed.
Today's Date

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