Facial Consent Form

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

How do you prefer to be contacted?*

Phone CallText

Have you had a facial before?*

YESNO

Have you ever had any issues with your previous facials?*

YESNO

What were the issues?*

Break outsReactionOther

What are your specific skincare concerns?*

What brings you in for a facial?*

Hyperpigmentation ConditionsAcne ConcernsMature SkinOther

Give us an idea of what you typically use on your skin daily?*

What is the skincare brand you use?*

I don't use skincareOther

Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO

Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescriptive creams or meds for skin?

Do you currently have any rashes, itching or underlying redness on your face?*

YESNO

Have you ever received any botox or fillers? if so, what location on your face and when? *

Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

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

Any known allergies?*

Please list medications or supplements you are currently taking.*

Medications or supplements

Have you experiences any of these health conditions in the past or present?*

Are you taking birth control?*

YESNO

Are you pregnant or breast-feeding?*

YESNO

Acknowledgement and Waiver I hereby agree to have this treatment. I am aware that products used in facials and homecare may contain tree nuts, sulfur, dairy, and gluten. I acknowledge that Miranda with MJM Beauty Studio LLC may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. Please inform your esthetican before treatment if severly allergic, as this may make you unable to receive the service. I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form and agree to update Miranda with MJM Beauty Studio LLC as to any changes. It is my responsibiliy to disclose all medical, medicinal, and skin history, as Miranda with MJM Beauty Studio will not be responsible to reactions caused by undisclosed medical history. I acknowledge that MJM Beauty Studio LLC does not provide medical advice and I accept full responsibility to seek out advice before receiving any services or products from MJM Beauty Studio LLC. I hereby release, discharge and waive all claims against MJM Beauty Studio LLC and Miranda and representatives or any person(s) performing services or applying any products at MJM Beauty Studio LLC, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

If I receive a Dermaplane treatment I acknowledge and understand while the goal of this treatment is superficial exfoliation and removal of vellus hair (peach fuzz), I may receive added improvements such as reduction in the appearance of fine lines & temporary fading of pigmentation. I acknowledge that this treatment may not be given, if my skin has excessive acne, lesions, moles, or skin tags. The esthetician will work around bumps, but if the skin was too many, Miranda at MJM Beauty Studio LLC may recommend a different treatment plan. I acknowledge Dermaplane treatment is not an exact science and that no specific guarantees can or have been made concerning the expected result. understand Dermaplane is a form of manual exfoliation using an esthetician grade, sterile blade which is mildly abrasive to gently “shave off” dead skin cells from the epidermis. It also temporarily removes fine vellus, leaving a smooth surface. Therefore, I will follow the explicit after care instructions of my skincare therapist. *

Initial

If I receive a SkinWave Treatment, I acknowledge that my skin may experience temporary irritation, tightness, or redness, which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that by failing to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & potential hyperpigmentation. Avoid excessive sun exposure especially, between 10am-2pm. I have disclosed my history of allergies via the medical history form and acknowledge that I may experience an allergic reaction. I hereby agree to have the Skinwave treatmen. I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen in the treated areas for a minimum 2 weeks pre and post-treatment. I acknowledge that I have answered all questions truthfully and completely. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and /or skincare practitioner per and post the treatment. I release MJM Beauty Studio LLC, and Miranda from any and all liability associated with any injuries and/or current or futureconditions resulting from the skincare procedures or products. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used without my written approval. By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate, and up-to-date to my knowledge. *

Sign name and date

I authorize Miranda with MJM Beauty Studio LLC to perform Microchanneling on my skin, and to apply topical preparations as determined necessary. I understand that Microchanneling is non-ablative skin rejuvenation / hair rejuvenation and involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin / hair. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin / scalp as well as rare side effects such as infection & scarring. These effects have been fully explained to me before treatment. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, type of hair loss and my compliance with pre/post treatment instructions. I understand that the Microchanneling treatment may involve a series of treatments. I understand there will be NO refunds for any services I receive.I understand Red light therapy will enhance and accelerate the procedure.I consent to the use of Red light therapy.I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and “not do” before, during and after the procedure.I consent to the taking of photographs and authorize their anonymous use for the purposes of clinical audit, education and promotion.I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.I have been made aware of the referral program my practitioner offers.I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein. *

Sign name and date

I acknowledge that the success of my treatment depends on me and I have an obligation to follow the written and spoken instructions concerning pre and post treatment care in order to achieve optimal results. *

Initial

Signature

Facial Questionnaire & Consent

Your Medical History

Female Clients

Dermaplaning, SkinWave, Microchanneling