Facial Consent and Release Form

CLIENT CONSULTATION AND RELEASE FORM

Please read carefully, complete, sign and date this form prior to your treatment.
Name

First NameLast Name
Phone
Format: (000) 000-0000.
Address
City
State
Zip
Email
Birthday Date

MonthDayYear
Date
Section 1: MEDICAL INFORMATION
Do you have any of the following allergies?

Other
Please check all that apply:
If you answered YES to any of the above questions please explain
My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyperpigmentation, scarring, etc.)
Specify your areas of concern (i.e. eyes, forehead, etc.)
SECTION 2: CLIENT CONSENT FORM Please check box to acknowledge
By signing below, I certify that I have read and fully understand the contents of this consent form and that the information I provided above are complete, accurate and up-to-date to my knowledge.
Client Signature
Date

MonthDayYear
Date
Should be Empty: