• Consent + Consultation Form

  • Date of Appointment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Are you currently under the care of a physician?*
  • Have you experienced any of these health conditions in the past or present?*
  • Are you pregnant or breast-feeding?*
  • Any known allergies or sensitivities?*
  • Do any of the following apply to you?*
  • Please rate your stress level*
  • How would you describe your skin?*
  • Do you experience any breakouts or acne?*
  • Have you been diagnosed with eczema, psoriasis, dermatitis, rosacea?*
  • What skin care products do you use on a daily basis?*
  • Are you currently using any products that contain:*
  • Do you currently use any of the following?*
  • Have you received any of these services in the last 7 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?*
  • Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
  • Do you use a tanning bed or are you considering using one soon?*
  • I consent to before and after pictures and/or videography for the purposes of marketing and business purposes*

  • I have read and understand the information provided to me by my esthetician.

    I agree to follow all home care regimens recommeded and provided to me by my esthetician to ensure the best results possible and prevent sun damage by applying proper SPF.

    I agree to contact my esthetician immediatley if I have any questions or concerns post wax or facial procedure.

    I agree that I have provided accurate and up to date information for the questions listed in this consent for for my esthetician, so that she is able to provide me with the best treatment and options for my skincare concerns and waxing needs to minimize any negative reactions or contraindications.

    I understand that if I do not provide all of the information above there are risks involved and do not hold Balance Beauty Studio and it's staff liable. I give consent for all future treatments.

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

    I release Balance Beauty Studio and the esthetician's whose signature appears below and it's staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Practitioner: Amber Buys

    FT-10210959
    HA-10210960
    IC-10211517
    NT-10210785

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