Facial Consent Form

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

How do you prefer to be contacted?*

Phone CallText

Have you had a facial before?*

YESNO

Have you ever had any issues with your previous facials?*

YESNO

What were the issues?*

Break outsReactionOther

What are your specific skincare concerns?*

What brings you in for a facial?*

Skincare EducationMature exfoliationRelaxationOther

Give us an idea of what you typically use on your skin daily?*

What is the skincare brand you use?*

I don't use skincareOther

Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO

Are you currently using any products that contain:*

Do you currently have any rashes, itching or underlying redness on your face?*

YESNO

Have you ever received any botox or fillers? if so, what location on your face and when? *

Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO

Any known allergies?*

Please list medications or supplements you are currently taking.*

Medications or supplements

Have you ever experienced claustrophobia?*

YESNO

Have you ever experiences vertigo or issues laying flat?*

YESNO

Have you experiences any of these health conditions in the past or present?*

Are you taking birth control?*

YESNO

Are you pregnant or breast-feeding?*

YESNO

Acknowledgement and Waiver

I hereby agree to have this treatment. I am aware that products used in facials and homecare may contain tree nuts, sulfur, dairy, and gluten. I acknowledge that Beauy by Emily Kay may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. Please inform your esthetican before treatment if severly allergic, as this may make you unable to receive the service.

I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form and agree to update Beauty by Emily Kay as to any changes. It is my rresponsibility to disclose all medical, medicinal, and skin history, as Beauty by Emily Kay will not be responsible to reactions caused by undisclosed medical history.

I acknowledge that Beauty by Emily Kay does not provide medical advice and I accept full responsibility to seek out advice before receiving any services or products from Beauty by Emily Kay. I hereby release, discharge and waive all claims against Beauty by Emily Kay and each of their employees, and representatives or any person(s) performing services or applying any products at Beauty by Emily Kay, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

Signature*

I acknowledge and understand while the goal of this treatment is superficial exfoliation and removal of vellus hair (peach fuzz), I may receive added improvements such as reduction in the appearance of fine lines & temporary fading of pigmentation. I acknowledge that this treatment may not be given, if my skin has excessive acne, lesions, moles, or skin tags. The esthetician will work around bumps, but if the skin has too many, the esthetician at Beauty by Emily Kay may recommend a different treatment plan. I acknowledge Dermaplane treatment is not an exact science and that no specific guarantees can or have been made concerning the expected result. *

Initial

I understand Dermaplane is a form of manual exfoliation using an esthetician grade, sterile blade which is mildly abrasive to gently “shave off” dead skin cells from the epidermis. It also temporarily removes fine vellus, leaving a smooth surface. Therefore, I will follow the explicit after care instructions of my skincare therapist. *

Initial

I understand that if I add glycolic or other chemical peel solutions onto my Dermaplane that I may achieve greater results, but I will also assume greater risks and have discussed these risks with my skincare therapist.*

Initial

Contraindications: While its impossible to list every risk and complication (contraindications) that comes with dermaplane, I must disclose some prior to treatment: Waxed or used hair remover within a week, active infection of any kind, active acne, sunburn, recent use of topical agents(glycolic acid or retin a), any recent chemical peel, uncontrolled diabetes, eczema/dermatitis, skin cancer, vascular lesion, inflammatory rosacea, tattoos/permanent makeup, peels or exfoliations within the past week, pregnancy/trying/breastfeeding, used acutane in the last year, family history of hypertrophic scarring or keloid formation, allergic to aspirin, fruit extract or milk, facial injection/electrolysis in the last 10 days.

Initial

I acknowledge that the success of my treatment depends on me and I have an obligation to follow the written and spoken instructions concerning pre and post treatment care in order to achieve optimal results. *

Initial

Prior to first appointment, BBEK will conduct a skin analysis and if microdermabrasion isn’t fitting, you will be notified and a new course will be taken. If microdermabrasion is for you, maximum results are achieved by routine appointments and an at home regimen.

Initial

BBEK takes every precaution to ensure your skin is well hydrated and calm prior to leaving each session. However, you may experience excessive dryness and peeling in between sessions which may or may not be normal. Sensitive skin will experience more redness which typically goes away within 2-3 hours.

Initial

After your treatment sunblock MUST be applied always and you must avoid tanning beds or anything UV light.

Initial

Contraindications: While its impossible to list every risk and complication (contraindications) that comes with microdermabrasion, I must disclose some prior to treatment: Waxed or used hair remover within a week, active infection of any kind, active acne, sunburn, recent use of topical agents(glycolic acid or retin a), any recent chemical peel, uncontrolled diabetes, eczema/dermatitis, skin cancer, vascular lesion, inflammatory rosacea, tattoos/permanent makeup, peels or exfoliations within the past week, pregnancy/trying/breastfeeding, used acutane in the last year, family history of hypertrophic scarring or keloid formation, allergic to aspirin, fruit extract or milk, facial injection/electrolysis in the last 10 days.

Initial

Post Op: Please avoid exercise til redness is gone. No direct sunlight exposure (including any UV). If exposure cannot be avoided apply sunscreen of atleast 15 SPF. Sunscreen should be an essential part of your daily skincare regimen, but for the next two weeks its imperative to wear SPF.

Initial

Select if you agree

Not on any steroids (oral or topical)No use of Retin A for 1 weekNo chemical peels or exfoliation in last week.

I give Beauty by Emily Kay to Publish photos of my service for her Business use.

Initial if allowed to use photos

Facial Questionnaire & Consent

Your Medical History

Females Clients

Dermaplane Consent

Microdermabrasion Consent

Media Release