Facial
Consultation & Consent Form
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Do you have concerns about any of the following?
*
Discoloration
Acne Scarring
Uneven Texture
Fine Lines and Wrinkles
Enlarged Pores
Loss of Facial Contours
Oily Skin
Dilated Capillaries
Lax or Sagging Skin
Acne/Breakouts
Redness
Dark Under Eye Circles
None of the above
What type of skin do you think you have?
*
Dry
Normal
Combination
Oily
Do you have a history of acne?
*
Yes
No
Do you use Retin A?
*
Yes
No
Have you ever used Accutane?
*
Yes
No
Do you use products with glycolic acid?
*
Yes
No
Have you ever had an acid peel?
*
Yes
No
Are you claustrophobic?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Do you sunbathe or use tanning beds?
*
Yes
No
Please list any allergies
Please list any health conditions that could affect your treatment
Are you okay with having CBD skincare products used on your skin?
*
Yes
No
I understand that if I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the above treatment/procedure that we have discussed and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion, and to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.
*
Submit
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