Facial consent form!

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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COPY OF DIVERS LICENSE or STATE ID * This field is required.As a private license and insured esthetician I must keep records of clients + services. This is also a second layer of safety for myself as I am a solo esthetician.
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Sex* This field is required.
Please Select
Please Select
Female
Male
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Occupation: blanks * Does your job require that you work outdoors? Yes No * What would you like to achieve from your treatment? Response *
7
YOUR SKIN CARE* This field is required.Which of the following best describes your skin type? ( Please select one)
Please Select
Please Select
Type I: Fair skin tones that always burn, never tan.
Type II: Light skin tones that burn easily, tan slightly.
Type III: Fair to Olive skin tones that burn moderately, tan moderately.
Type IV: Light brown skin tones- Burn slightly, tan easily.
Type V: Dark brown skin tones that rarely burn, tan easily.
Type VI: Dark brown to black skin tones that never burn, tan easily.
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Have you ever had a facial before?    Yes     No *    If yes, when was your most recent facial?    *

Have you ever had chemical peels, laser treatments or microdermabrasion?    Yes     No *

Have these treatments been in the last 4 weeks?    Yes     No *

Do you use Accutane, Retin_A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?    Yes     No *
If yes, what and when did you last use it?    *

Have you used acne medication?    Yes     No *
If yes, what and when did you last use it?    *

Have you experienced Botox, Restylane, or collagen injections?    Yes     No *           If yes, please specify:    *
9
What areas of concern do you have regarding your skin?Check all that apply
Breakouts/ Acne
Sun damaged skin
Rosacea
Flaky skin
Sun/Liver/Brown spots
Uneven skin tone
Excessive oil/Shine
Dull/dry skin
Redness/Ruddiness
Blackheads/White heads
Wrinkles/Fine lines
Broken Capillaries
Dehydration
Other
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Have you ever had an allergic reaction to any of the following?* This field is required.Check all that apply
Cosmetics
Fragrances
Animals
Drugs
AHAs (alpha hydroxy acids)
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Other
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Have you had any recent tanning or sun exposure that changed the color of your skin?    Yes     No *          If yes, please specify when:    *

Are you taking oral contraceptives?    Yes     No *          If yes, please specify:    *

Any recent changes to or from your contraceptive treatments?    Yes     No *          If yes, please specify what and when:    *

Are you pregnant or trying to become pregnant?    Yes     No *

Are you experiencing any menopausal symptoms?    Yes     No *          If yes, please specify:    *

Are you undergoing any hormone replacement therapy treatments?    Yes     No *          If yes, please specify:    *

Do you experience irritation from shaving?    Yes     No *          If yes, where do you experience the most?    *

Do you experience ingrown hairs as a result of hair removal?    Yes     No *
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Signature* This field is required.I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skincare professional from liability and assume full responsibility thereof.
13
Facial service Deposit* This field is required.
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My Bag
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Facial Deposit
Facial depoist is non refundable and can be transferred once if client has rescheduled at least (minimum) 2 days prior to booked appointment.
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Quantity
Total cost
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to the Afterpay to complete the payment process.
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