Skin Treatment Consent Form

Skin Treatment Consent Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date

Please select the suitable ones that describe your skin

	Always	Moderately	Seldom	Rarely	Never	Not Applicable
Easily sun burn
Deep tans

Please give details about the products you use for your skin.
skincare, etc.
Are you currently taking any medical or dental treatment?

YesNo
Please give details ( Don't forget to write the medications you use)
As far as you know do you have any allergies?

YesNo
Please give details
Have you used any hormonal contraceptives lately?

YesNoNot applicable
Are you pregnant or breast feeding right now?

YesNoNot applicable
Please select if you suffer from any of the conditions listed below

PsoriasisEczemaDiabetesHay-feverSensitive skinEpilepsyCold soresHerpesBlood borne diseasesOther
Did you have any laser treatments or chemical peels in the last two month?

YesNo
Which one(s) do you want to solve with this treatment?

Allergy prone skinExcessive hairDehydrationWrinklesSensitivityThin lipsBreakoutsDrynessCrows feetScarringPost AcneSun damageOpen poresTightnessAgingHot flushesRosaceaSunspotsItchinessReduce elasticityCapillariesFlushingPigmentationSpider veinsFine linesCoarse skinFrown linesBlackheadsOilinessIncreased pore sizeOther
Purpose of the Consent: This consent form is written to ensure there is an ongoing communication process between the client and Esthetician. It is important that the client fully understand the risks and complications of the treatment and asked any question before the treatment started. Risks and Side Effects: The possible side effects are listed below. However, the client should be aware that there may be unique effects to certain people that are not known right now. The skin might experience temporary irritation, tightness, redness, or slight swelling. The skin may experience temporary or permanent color change, Herpes infections may be reactivated if there is a prior history. The skin may experience a flare of acne-like lesions.
I agree with the following statements

I have given enough information about the procedures, risks and side effects of the skin treatment that I am to undergo. I asked all of my questions to my Esthetician and got the answers I need. By considering all aspects I decided to undergo the skin treatment of my own accord. I will not be able to sue my Esthetician in case of complications or ask for return in the case of not satisfactory results.I have informed about alternative treatments and I decided to take skin treatment on my own accord.I will follow the after treatment advices given to me by my Esthetician.I had enough time to think, consider alternatives and ask questions about the treatment.I understand every question asked above and answer them truthfully.I AM GIVING MY CONSENT TO RECEIVE SKIN CARE TREATMENT BY MY ESTHETICIAN.
Date

MonthDayYear
Date
Signature

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