Facial Consent Form

Mode Beauty NYC

Skin History and Facial Service Consent Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address (I like to send birthday cards and a little note after your first visit—just a personal touch, no marketing or spam, ever.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
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Instagram Handle
Share your Instagram handle, and I’ll follow your account so we can stay connected and keep up with each other!
How did you hear about us?

Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you experienced any of these health conditions in the past or present?

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesEczemaDermatitisPCOSOther
Any known allergies?
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Please check if pregnant or nursing

PregnantNursing
Have you ever experienced claustrophobia?

YESNO
Please rate your stress level

LowMediumHighNone
Tell Me About Your Skin & Routine
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
Do you experience routine breakouts or acne?

YESNO
What are your skin concerns?
Describe what you would like to achieve today?*
What services are you considering for the future?
What skin care products do you use on a daily basis?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
What brand/s of skincare products do you use?
How many steps feel realistic for your daily skincare routine?

3-55-8I'm not sure
Do you currently use:*

AccutaneRetin-APrescribed topical creamNone
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsNone
Please specify which product or type, if you answered YES to the question above.
Have you received any of these facial hair removal services in the last 7 days?*

Waxing/sugaringThreadingLaser/ElectrolysisNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Do you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Have you ever had a facial treatment you were unhappy with?
Why did you leave your last esthetician?
How often do you like to come in for facial treatments?
Is there anything else you would like me to know?
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 7-14 days following treatment or as directed by my specialist.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Mode Beauty NYC and staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Initial Here*
I acknowledge that I must adhere to Mode Beauty NYC’s cancellation and late policies. I understand that appointments should be canceled with at least 24 hours notice to allow availability for other clients.

I also understand that if I arrive more than 10 minutes late, my appointment may need to be adjusted, rescheduled, or canceled based on the remaining time available.
Initial Here*
At Mode Beauty NYC, your satisfaction is my top priority. If, for any reason, you’re not fully satisfied with your service or product, I kindly ask that you adhere to the following guidelines:

If you have any concerns about a service or product, please reach out to me directly within 24 hours of your appointment or purchase.

Before posting a review or sharing your concerns on social media, I kindly request that you allow me the opportunity to address and resolve the issue. My goal is to ensure you leave feeling confident and cared for.

If necessary, I may request that you come in for an in-person assessment. This will allow me to better understand your concerns and determine the best course of action to address them.

Please note that all services and packages are non-refundable. However, I am committed to doing everything possible to make your experience positive and meet your expectations.

Exchanges for products may be available within 24 hours of purchase at my discretion. Please provide details about your concerns to help me better understand how to assist you.

By initialing here, I acknowledge and agree to these terms
Initial Here*
PHOTOGRAPHY CONSENT
I grant my permission to be photographed and/or video recorded by my treatment provider in order to keep a thorough record of my treatment progress and to promote the skincare services of this facility and my treatment provider. I understand that the images and/or recordings may be used in print and/or online publications, presentations, websites, and social media. I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I also understand that the images may be retouched as seen fit by my treatment provider. I consent to these terms on the condition that I will be made aware at the time of any and all photography/recordings, and none shall be taken without my knowledge.
Check One*

I give consent for my images and/or recordings to be used in print and/or online publications, presentations, websites, and social media.I DO NOT give consent for my images and/or recordings to be used in print and/or online publications, presentations, websites, and social media
Signature*

Clear
Date*

MonthDayYear
Date
Parent of signature of guardian if under 18

Clear
Should be Empty:

Mode Beauty NYC

Your Medical History

Tell Me About Your Skin & Routine