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 Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Occupation.
Does your job require you to work outside?
Please Select
Yes
No
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?
Yes
No
If "Yes" when?
Date
Which of the following best describes your skin type?
Creamy complexion –always burns easily, never tans
Light complexion –always burns, tans slightly
Light/matte complexion –burns moderately, tans gradually
Matte complexion –seldom burns, always tans well
Brown complexion –rarely burns, deep tan
Black complexion –never burns, deeply pigmented
Do you have any skin conditions pertaining to your face or body?
Yes
No
If "Yes" please explain.
Have you ever had chemical peels, laser or microdermabrasion?
Yes
No
If so, When?
Have you had any Botox, Restylane, or Collagen injections?
Yes
No
If so, When?
Do you currently use Rentin-A, Adapalene Hydroxyl Acid or Rentinol/vitamin A derivative products?
Yes
No
Have your used Rentin-A, Adapalene Hydroxyl Acid or Rentinol/vitamin A derivative products within the last 3 months?
Yes
No
Do you currently or within the last 3 months take any other acne medication?
Yes
No
If so, please specify which drug and last dosage:
Have you recently used any self-tanning lotions, creams, or treatments?
Yes
No
If so, When?
Have you used any of the following hair removal methods in the past 6 weeks?
Shaving
Waxing
Electrolysis
Plucking
Threading
Depilatories
What areas of concern do you have regarding your skin?Please check all that apply:
Breakouts/acne
Excessive oil/shine
Rosacea
Broken Capillaries
Redness/ruddiness
Sun, liver, or brown spots
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull or dry skin
Flaky skin
Dark circles
Puffiness
Cracked/chapped lips
Other
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.
*
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I understand
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
I Agree
No Thank you
Please select
Female Clients Only:
Are you currently taking oral contraceptives
Yes
No
If "Yes", Please specify
Any recent changes to or from your contraceptive treatment?
Yes
No
If "Yes", Please explain
Are you Pregnant?
Yes
No
If "Yes", Please specify
Are you lactating?
Yes
No
If "Yes", Please explain
Any Menopause problems?
Yes
No
If "Yes", Please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If "Yes", Please specify
Male Clients only:
What is your current shaving system? Please check
Wet shave
Electric
Shaving cream
After shave
Do you experience irritation from shaving?
Yes
No
Ingrown Hairs?
Yes
No
I am 18 years or older
Yes, I am 18 years or older
No I am not 18 years old. I have parental or guardian consent with a signature below
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.
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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.
*
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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.
*
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Today's Date
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Month
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Day
Year
Date
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