BACK TREATMENT FACIAL CONSENT FORM

This form is for Back facial not face facial. Please go back and select customized Facial. Please and thank you! 😊

Name *

First Name Last Name

Date of birth *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Occupation *

Email *

example@example.com

Please list any skin or health conditions you are experiencing

How often do you excerise? *

What is your level of stress?

How much water do you drink a day? *

How much UV exposure do you get (sun, tanning beds, commuting in car) *

Do you have any of the following:

Scars Stretch Marks Hyperpigmentation None

Do you suffer from:

Acne Oilliness Psoriasis Blackheads Dehydration Eczema Cellulite None

Have you had a back facial/ treatment before? *

Yes No

If yes, when was your last session?

What are your major concerns for today’s session? *

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information and providing missinformation may result in a contraindications and/or irritation to the skin from treatments receive. The treatments I receive her are volunteer and I release institution and/or the technician/aesthetician/skin care professional from liability and assume full responsibility there of.

I understand if Any cancellations or rescheduling with less than 24 hours of notice or no-show appointments are subject to a cancellation fee amounting to 50% of the cost of the scheduled service.

I understand NO REFUNDS. All purchases are FINAL SALE.

I understand the above statements

Yes

Signature

Clear

Date

BACK TREATMENT FACIAL CONSENT FORM

MEDICAL/HEALTH BACKGROUND