General Consent Form

GENERAL CONSENT FORM
CONTACT INFORMATION
Date

MonthDayYear
Date
Name

First NameLast Name
M.I.
Date of Birth

MonthDayYear
Date
Age
Cell
Work/Home
Email
example@example.com
Address

Address

Street Address Line 2

CityState

Zip
Emergency Contact
Relationship
Emergency Phone
Format: (000) 000-0000.
How were you referred to us?
Which of the following best describes your skin type? (Check one)
Are you currently under the care of a Physician?
If yes, for what?
Are you currently under the care of a Dermatologist?
If yes, for what?
Do you have any of the following medical conditions? (Check all that apply)
Have you had any surgery where lymph nodes were removed?
Do you have any other health problems or medical conditions? Please list
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using oral contraception?
HALE&HUSH
GENERAL CONSENT
Have you had an allergic reaction to any of the following?: (please check all that apply & describe the reaction you had)

Other
Have you ever had a skin reaction to a fragrance?
Please list any fragrances with issues
Please list all medications you are currently taking
Topical medications
Herbal Supplements
Have you ever used Accutane?
If yes, when did you last use it
Have you used any of the following for hair removal in the last six weeks?
Have you had any recent tanning or sun exposure that changed the color of your skin?
Have you recently used any self-tanning lotions or similar treatments?
Do you form thick raised scars from cuts or burns?
Have you ever had hyper-pigmentation(darkening of the skin) or Hypo-pigmentation(lightening of the skin) or marks after physical trauma?
If yes, please describe
What type of climate do you live in?
Occupation
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the Esthetician, Technician, Therapist, Doctor or Nurse of my current medical and health history and to update any current conditions. A current medical history is essential for the caregiver to execute the appropriate treatment procedures. (All information is strictly confidential)
Signature
Date

MonthDayYear
Date
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GENERAL CONSENT FORM

CONTACT INFORMATION

HALE&HUSH

GENERAL CONSENT