Complexions by Ericka

Name*

First NameLast Name

Date*

MonthDayYear

Date of Birth *

MonthDayYear

Email*

example@example.com

Address*

Street Address

CityState

Postal / Zip Code

Phone Number*

Area CodePhone Number

Have you ever received any botox or fillers? if so, when?

LowMediumHighNone

YESNO

What are your skin concerns?

Waxing/sugaringThreadingLaser/Electrolysis

YESNO

AccutaneRetin-APrescribed topical cream

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs

YES, within the last monthYES, within the last 2-3 monthsNO

I acknowledge that I must adhere to Complexions by Ericka policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in a 35$ charge. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.

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 fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

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 2-4 weeks following treatment.

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

Signature

Complexions by Ericka

Your Medical History

Your Skin