Facial Consent Form

Date

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Format: (000) 000-0000.

How did you hear about us?

If referred, by who?

Have you had any of the following past or present?

Any known allergies?

Are you on birth control?

Are you pregnant or trying to get pregnant?

Are you nursing?

List medications/supplements you are currently taking.

Please rate your stress level

What is the reason for your visit today? Do you have any areas of special concern?

Which conditions would you like to improve?

What skin care products do you use on a daily basis?

Are you planning on purchasing products today?

Have you ever received any botox or fillers?

Do you experience routine breakouts or acne?

Have you been diagnosed with eczema, psoriasis or rosacea?

Have you received any of these facial hair removal services in the last 7 days?

Do you currently use:

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

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

Do you?

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 (SPF 30+), I am more susceptible to sunburn, skin damage & hyperpigmentation.

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 and hold harmless the skin care professional, Jennifer Carrera, Jlc Esthetics and its staff from any liability for adverse reactions that may result from this treartment.

Signature

Client Questionnaire

Tell us about your skin

Informed Consent Release