Client Consent Form

Full Name *

First NameLast Name

Today’s Date

Date

Email

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name and Number *

How did you hear about us? If Referred by someone please list who. *

What are your aesthetic concerns & what would you like to achieve? *

List any current or previous medical history and any surgical procedures *

List any prescribed or over the counter medications you are currently taking including any prescribed skin products or topical creams *

List any allergies or sensitivities you may have *

If getting a facial, do you have sensitive skin? Does your skin get red or irritated when using new products or when exposed to heat?

Are you currently pregnant or lactating ? *

Do you consent to photos or videos of your treatment for the use of media purposes ? *

I blanks* consent to receiving blank treatment, and have answered all the questions listed above truthfully. I Also Understand that if I have not answered all questions truthfully any complication that may occur Aesthetically Touched will not be held liable.

Signature

I understand all sales are final, there is no refunds, deposits are non refundable. Initial bellow.