Skincare Consultation Consent Form

Consultation Consent Form

Great! You have taken the first step to healthier skin. During your consultation appointment, you will discuss your skincare needs with a Licensed Esthetician. Our professional team will listen to your skin concerns, answer questions, give product recommendations and advice for the best results. Also, you will receive a Sacred Beauty gift card following your appointment! Please fill out form below , set appointment and pay $60.00 for 1 hour session.
Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
How did you hear about us? *

Facebook/Instagram Online Search Referral
If referred, by who?
Your Medical History
Are you currently under the care of a physician? *

YES NO
Have you experiences any of these health conditions in the past or present?

Hormone Imbalance Cancer/ Systemic disease High Blood Pressure Diabetes Heart problem Arthritis Auto-immune Disorder Asthma Epliepsy/Seizures Cold sores HIV/AIDS Lupus Depression/Anxiety Headaches/ Migranes None
Any known allergies? *

Asprin Latex Fruits Shellfish Lidocane Fragrance/essential oils Tree Nuts Dairy Sunscreen Pollen None
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Please rate your stress level

Low Medium High None
Your Skin
What are your skin concerns?
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture) Sensitive (reactive to fragrance, often irritated) Combination (oily and dry patches, oily t-zone, hormonal breakouts) Oily (enlarged pores, excessive oil) Acne (cystic or nodules) Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis? *

Soap Cleanser Toner Serum Mask Exfoliant (physical or chemical) Eye Cream Moisturizer SPF Vitamin A (retinol)
Do you experience routine breakouts or acne?

YES NO
Have you been diagnosed with eczema, psoriasis or rosacea?

YES NO
Do you currently use:

Accutane Retin-A Prescribed topical cream
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.) BHA (salicylic acid) Vitamin A derivative (retinol/retonids) Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month YES, within the last 2-3 months NO
Female Clients
Are you taking birth control?

YES NO
Are you pregnant or breast-feeding?

YES NO
I acknowledge that I must adhere to Sacred Beauty Skincare policies. I understand that cancellations must be done with at least 24 hours notice. Failure to do so will result in the loss of skincare consultation. I acknowledge that ANY no show will result in 100% loss 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 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 consultation. I give consent for all future treatments

I release Sacred Beauty Skincare and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare consultations or suggested products.
Signature

Clear
Appointment
My Products
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Skincare Consultation $ 60.00
This payment is to secure your Zoom meeting call with our licensed esthetician. The duration of this meeting will be the maximum of 1 hour. This payment is non-refundable and non-transferable.

Session

Total $ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Consultation Consent Form

Your Medical History

Your Skin

Female Clients