Elle Marie Spa: Skincare Facial Consent Form

Date *

Date

Name *

First Name Last Name

Date of Birth *

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?

Are you currently under the care of a physician? *

YES NO

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

Any known allergies? *

Have you ever received any botox or fillers? if so, where and when?

Have you ever experienced claustrophobia?

YES NO

What do you wish to achieve with your skin’s health and appearance?

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? *

How often do you receive facial treatments?

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

What brands of products do you currently use? What do you like in your current home care routine? What do you feel could be improved in your home care routine?

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

YES, within the last month YES, within the last 2-3 months NO

What medications, herbs, and vitamins do you take?

How many ounces of water do you drink per day?

What does your diet typically consist of?

From 1-10, rate your stress level

Do you?

Wear contact lenses Have a pacemaker Have metal implants Smoke Consume Alcohol Consume Caffeine Frequent tanning beds

Are you taking birth control?

YES NO

Are you pregnant or breast-feeding?

YES NO

Conversation preferences

I prefer to discuss my goals during our treatment and be informed of what you’re applying to my skin. I prefer to relax and keep conversation to a minimum.

I acknowledge that I must adhere to Elle Marie Spa's policies:

Cancellations: We allow cancellations 24 hours prior to your appointment. Cancellations less than 24 hours will result in a 50% charge and a No Show will result in a 100% charge on your gift card or credit card.

Check In: Please check in at least 10 minutes prior to your reservation. If you arrive late for your appointment, you risk having your appointment shortened so that we can accommodate the next scheduled guest.

Gratuities: The price of your service does not include gratuity. We recommend a 15% to 20% gratuity for your service provider.

We thank you in advance for respecting these and look forward to making your day amazing!

I agree

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

Clear

Elle Marie Spa

Your History

Your Skin

If Applicable,

Your Service

Your Promise