New Client Consultation Form

Facial Consent Form
Name*

First NameLast Name
Date*

MonthDayYear
When was your last facial?*
Are you currently

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:
Best Described Skin Type

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.
Had chemical peel, laser or microdermabrasion before?

yesno
Get irritated from shaving?

yesno
Do you exfoliate?

yesnosometimes
I knowingly and willingly consent to having skin care service(s) during the COVID-19 pandemic.*

by checking this box I understand and accept this statement.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing.*

by checking this box I understand and accept this statement.
I confirm that I have or have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days*

YESNO
I verify that I have not traveled outside the United States In the past 14 days to countries that have been affected by COVID-19*

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