New Client Consent Form
Must be filled out by every brand new client prior to first appointment
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
How did you hear about Brand New You Esthetics?
*
Please Select
Tik Tok
Instagram
Referral
Facebook
Referred by a friend
(if referred) put down below by who:
Emergency contact name and number
*
What are your skin goals and concerns
*
List any over the counter or prescription medications you are currently taking:
*
List any allergies or sensitivities you may have:
*
In the past have you been prescribed any oral antibiotics or topical antibiotics to treat any skin concerns. Ex. Accutane, doxycycline, etc.
Please Select
Yes
No
List any prescribed skin medication or topical cream you are currently using:
*
On a scale of 1-10 (10 being the most severe) how would you describe your stress/anxiety levels?
List any current or previous medical history AND any surgical procedures (ex. cancer, heart condition, etc.):
*
Are you currently pregnant or planning to be in the near future
*
Please Select
YES
NO
Below type the current skincare products you use
*
Do you wear SPF every day and reapply?
*
Please Select
YES
NO
How would you describe your skin?
*
Please Select
Normal
Combination
Dry
Sensitive
Acne Prone/Oily
Have you seen a dermatologist or esthetician before regarding your skin?
By signing this document I consent to have my picture being taken during this appointment. I understand that I give photo release by signing this document and my esthetician may use photos to track progress as well as those pictures possibly being used for social media marketing.
By signing this document I am stating that I filled in all the above information accurately and truthfully.
*
I hereby consent and authorize Breana Brand to perform my scheduled skin treatment.
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