New Client Consultation Form

Facial Consent Form
Name*

First NameLast Name
Date*

MonthDayYear
When was your last facial?*
Pregnantbreast feedingtaking Birth Controlhave any injuriesBotox fillerstaking GlycolicAHA/BHARetin-ARetinolAdapaleneAccutaneDifferinMandelic Acidhave cold soresmenopausesunburntsmokinghave cancer or systemic diseasehigh blood pressurediabetesarthritisepilepsy/seizure disorderasthmaherpes or hepatitislupusclaustrophobiadepressedhave anxietymigraineswear contactsusing skin thinning products
Allergies?
Medication or vitamins:
sensitivedehydrateditchy eyesrosaceaflakingfine lines/wrinklesoily t-zoneoily all overopen poreswhiteheadsblackheadspustulesbroken capillariesfrecklesunderlying congestionage or sun spotseasily burnedhyperpigmentationdark circles around eyestired eyesfacial hairdulleczemapsoriasis
What are your skin care goals?
Expectations for today's treatment?
I drink water cups of water and caffeine cups of caffeinated drinks per day.
yesno
yesno
yesnosometimes
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
YESNO
YESNO
I have read and filled out the information above. If I have any concerns I will address these to my therapist immediately. I give my therapist permission to perform any facial treatments and will hold her and her staff harmless from any liability that may result from treatments. I also, to my best knowledge, given any accurate account of my medical history, including all known allergies or prescription drugs or products I'm currently ingesting or using topically. I understand my skin therapist will take every precaution to minimize or eliminate any negative reaction as much as possible. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when receiving any treatment from the therapist signed below.*

by checking this box I understand and accept this statement.
Signature*
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Facial Consent Form