Beaute' Connection DG
Facial Consent Form
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?
*
Walked by
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
Other
Any known allergies?
*
Asprin
Latex
Fruits
Shellfish
Lidocane
Fragrance/essential oils
Tree Nuts
Dairy
Sunscreen
Pollen
None
Other
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Have you ever experiences claustrophobia?
YES
NO
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
Have you received any of these facial hair removal services in the last 7 days?
Waxing/sugaring
Threading
Laser/Electrolysis
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
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Smoke
Consume Alcohol
Consume Caffeine
Frequent tanning beds
Females Clients
Are you taking birth control?
YES
NO
Are you pregnant or breast-feeding?
YES
NO
I acknowledge that I must adhere to Pretty Please Haus of Vanity’s policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. 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 am allergic to one or more ingredients in the products used, I may experience allergic reactions. 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 this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. 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 I release Chateau Glow and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Signature
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