Earth N Soul's Facial Consent Form

CONFIDENCIAL
Name*

First NameMiddle NameLast Name
Date of Birth *

MonthDayYear
Date
Date of your appointment*

MonthDayYear
Date
Gender*

MaleFemale
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Emergency contact

Area CodePhone Number
How did you hear about us?*

Walked byFacebook/InstagramReferralGoogleYelpFriendsFacebook Group
If referred, by who?
Your Medical History
Are you currently under the care of a physician?*

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

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther
Please rate your stress level*

LowMediumHighNone
Personal History
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?*

YesNo
Have you experienced Botox, Restylane or Collagen injections within the past 4 weeks?*

YesNo
Within the last nine months, have you undergone any surgery or plastic surgery?*

YesNo
Are you currently using any products that contain the following ingredients?*

Glycolic AcidAcetic AcidAny exfoliating scrubAny hydroxy acid productVitamin A derivatives (i.e. retinol)RenovaNone of theseOther
Have you recently received any of the following treatment?*

MicrodermabrasionChemical peelMicroneedlingFacial WaxingLaser treatmentOther
Have you recently used any self-tanning lotions, creams or treatments?*

YesNoNone of theseOther
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*

YesNoNone of theseOther
Do you drink more than 4 caffeinated beverages a day (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia?*

YesNo
Does your job require that you work outdoors?*

YesNo
How much time do you spend in the sun, and what is your level of sun protection?*
Were you exposed to the sun for the past 48 hours?*

YesNo
Are you planning to do any outdoor activities or expose to the sun for the next 48 hrs?*

YesNo
Medical History
Please list all medications you are currently taking (including herbal, over the counter, topical, oral, and supplemental):*
Are you currently taking/using:*

AntibioticsAnti-inflammatory DrugsBlood ThinnersChemotherapyCorticosteroidsImmunotherapyInsulinRadiation TherapyTransplant Anti-Rejection DrugsTopical Creams (i.e., Azelaic Acid, Tretinoin, Retinoids, Antibiotics Creams, etc.)Topical photosensitivity creams/serums, such as AHA.None of the aboveOther
Have you ever had an allergic reaction to any of the following substances/ingredients?*

CosmeticsMedicationFoodAnimalsSunscreenLodinePollenSkin productsEssential OilsNutsAlpha Hydroxy Acids (AHAs)FragranceShellfishLatexAspirinNone of the aboveOther
Do you have any allergies to product ingredients, foods, medications, or any other allergies?*
Have you been diagnosed with/currently have:*

Autoimmune DisorderBlood Clotting DisorderCancerCollagen Vascular DiseaseDiabetesHeart Disease/HypertensionHerpes VirusHIV/AIDSImpaired Wound HealingNeuropathyThyroid IssuesNone of the aboveOther
Do you have any other medical issues not listed above that may affect your skin?*

YesNo
If yes, please describe issues here:
Do you have any surgically implanted metal devices, such as screws, plates, stents, or joint replacements? If yes, please specify the type of device and the area of your body where it is located.*
Do you currently have any of the following in requested treatment area(s):*

Active infection (viral, fungal, or bacterial)Active herpes/cold soresInflammationMalignanciesOpen lesionsRaised MolesSunburnTumorsWartsWeeping SoresVaricose VeinsVascular LesionsNone of the aboveOther
Your Skincare History
Have you ever had a facial treatment before? *

YesNo
Your skin types*

Normal skinDry skinOily skinCombination skinSensitive skinAging skinDehydrated skinRosacea-prone skinSun-damaged skinHyper pigmented skinPsoriasis-prone skinAcne-prone skinOther
What are your main skin concerns*

Acne, breakoutsBlackheadsDry SkinExcessive oil/shineDull SkinDehydrated skinFine lines and wrinklesDark circles under the eyesHyperpigmentation (dark spots)Sun damageAge spotsMelasmaScarsKeratosis pilarisRosaceaEczemaEnlarged poresSkin rednessUnder-eye puffinessUneven skin toneUneven skin texturePremature agingPsoriasisWhite headsExcessive facial hairFlaky skinSun/liver/brown spotsRedness/RuddinessBroken capillariesOtherIf ‘Other’, please detail:
Please detail:
Do you experience routine breakouts or acne?*

YESNO
If yes, how often?*

WeeklyOnce a MonthA Few Times Per YearOnly Recently
If yes, where do you breakouts?*

Chin/JawlineCheeksForeheadNoseNeck/Back
Have you ever been diagnosed with or treated for any of the following skin conditions?*

AcneCystsEzcema/DermatitisKeratosisKeloid ScarsPigmentationPsoriasisRosaceaScierodermaOtherNone of the aboveOther
Your skin routine*

Foam CleanserGel CleanserMakeup RemoverTonerMoisturizerEye creamSunscreenFace MaskExfoliantSerumSpot TreatmentFacial oilOther
When was the last time you exfoliated your skin?*

Within the past 7 days7-14 days agoMore than 14 days agoOver a month agoI don't exfoliate my skinOther
Have you used or been prescribed any medications (topical or oral) for acne or acne control for example Accutane within the last 3-6 months? If yes, when and which drug?*
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
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 scrubsNone of these
Have you ever received chemical peels, laser services, microdermabrasion, or injection treatments?*

YES, within the last monthYES, within the last 2-3 monthsNOOther
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Females Clients
Are you taking birth control?

YESNO
Are you having your circle?*

YES (Lightly)YES (Heavy)No
Are you pregnant or breast-feeding?*

YESNO
Are you pregnant or trying to become pregnant?*

YesNo
Are you experiencing any menopausal symptoms?*

YesNo
Are you undergoing any hormone replacement therapy treatments?*

YesNo
Male Client
Do you experience irritation from shaving?*

YesNo
Do you experience ingrown hairs as a result of hair removal?*

YesNo
Goal
What are your expectations and goals for the treatment? What would you like to improve?*
How do you prefer to be guided during your treatment?*

I prefer to have a conversation and be guided throughout the treatment.I prefer a quiet, relaxing experience with minimal conversation.I am flexible and can go with either option.Other
Please Upload Your Picture
Please upload your front face *

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Please upload your left face

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Please upload your right face

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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.
I affirm the above information is accurate to the best of my knowledge. I acknowledge that Skin Sculptor Studio Staff are not responsible for any errors that may occur as a result of any omissions or incorrect information on this form.
Signature*

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Provider

First NameLast Name
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CONFIDENCIAL

Your Medical History

Personal History

Medical History

Your Skincare History

Females Clients

Male Client

Goal

Please Upload Your Picture