SKIN LAB TREATMENT CONSENT FORM

Date

Name

Date of Birth

Date

Phone Email

Emergency Contact Phone

Procedure

THE FOLLOWING INFORMATION WILL BE USED TO HELP PLAN SAFE & EFFECTIVE FACIAL SESSIONS EACH TIME YOU VISIT Dolce Vita Aesthetics.

IT IS IMPORTANT THAT YOU ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE WITH HONESTY. THANK YOU.

Within the last year, have you been under a dermatologist or other physicians care?

YesNo

If YES, please specify

Within the last nine months, have you undergone any surgeries?

YesNo

If YES, please specify

Have you had any health problems in the past year or present?

YesNo

If YES, please specify

Do you wear contact lenses?

YesNo

Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc., that you take

Please select your skin type:

Do you ever experience skin breakouts?

YesNo

Do you ever experience oily skin during the day?

YesNo

Do you experience burning or itching sensations on your skin?

YesNo

Have you ever experienced a reaction to any of the following?

Are you pregnant or trying to get pregnant?

YesNo

Do you have any special skin problems pertaining to your face or body?

YesNo

FACIAL CLIENT INTAKE AND RELEASE OF LIABILITY FORM

What products are you currently using?

Do you use Accutane, Retin A, Renova, Adapalene or other prescription skin products?

YesNo

If YES, please specify

Have you had any of the following treatments? Select all that apply.

Chemical PeelsMicrodermabrasionSkin Resurfacing Treatment

If yes, please specify date of treatment

Is there anything else about your current or previous health history you think would be useful for your esthetician to be aware of to make this a better experience?

I certify that the treatment/procedure is being given upon my request. I understand that the service provider does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. I acknowledge that facial services are not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary Health Care provider for that service. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that Dolce Vita Aesthetics by law has the right to refuse service on any client at any time, if they feel as though their well-being is compromised. I understand and voluntarily accept the risks associated with the facial and/or any other services, including but not limited to: Microneedling, HydraFacial, Acne facial, Microdermabrasion, Dermaplaning, Fibroblast Plasma. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or any side effects which may arise from the Treatment/Procedure performed. I agree Dolce Vita Aesthetics will not be liable for any of the above.

This agreement cannot be amended, except in writing by both parties. By signing this form, I agree to the above terms and release Dolce Vita Aesthetics from any liability

Client Signature

Date