Facial Consent Form

Facial Questionnaire & Consent

Please fill out completely
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
How do you prefer to be contacted?*

Phone CallText
Have you had a facial before?*

YESNO
Have you ever had any issues with your previous facials?*

YESNO
If yes, what were they?
What are your specific skincare concerns?*

Dry Flakey SkinBreakoutsWrinklesBlackheadsAcneLoss of FirmnessClogged PoresSkin TextureLarge PoresHyper-Pigmentation / Uneven Skin ToneRednessSkin SensitivityRosaceaOily SkinMiliaFine LinesNone of the aboveNone of the aboveOther
What brings you in for a facial?*

Skincare EducationAcne ConcernMature exfoliationOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
What is the skincare brand you use?*

I don't use skincareOther
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescriptive creams or meds for skin?None
Do you currently have any rashes, itching or underlying redness on your face?*

YESNO
Have you ever received any botox or fillers? if so, what location on your face and when? *
Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Your Medical History
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNoneOther
Please list medications or supplements you are currently taking.*
Medications or supplements
Have you ever experienced claustrophobia?*

YESNO
Have you ever experiences vertigo or issues laying flat?*

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
Females Clients
Are you taking birth control?*

YESNO
Are you pregnant or breast-feeding?*

YESNO
Acknowledgement and Waiver I hereby agree to have this treatment. I am aware that products used in facials and homecare may contain tree nuts, sulfur, dairy, and gluten. I acknowledge that the estheticians at Poise Beauty Bar may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. Please inform your esthetican before treatment if severly allergic, as this may make you unable to receive the service. I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form and agree to update Poise as to any changes. It is my responsibiliy to disclose all medical, medicinal, and skin history, as Poise Beauty Bar will not be responsible to reactions caused by undisclosed medical history. I acknowledge the esthetician at Poise Beauty Bar do not provide medical advice and I accept full responsibility to seek out advice before receiving any services or products from Poise Beauty Bar . I hereby release, discharge and waive all claims against Poise Beauty Bar and each of their employees, and representatives or any person(s) performing services or applying any products at Poise Beauty Bar, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
PHOTOGRAPH CONSENT

I give consent to have my picture taken and allow Poise Beauty Bar to use it for Social Media Advertising content.
Signature
Dermaplane Consent
I acknowledge and understand while the goal of this treatment is superficial exfoliation and removal of vellus hair (peach fuzz), I may receive added improvements such as reduction in the appearance of fine lines & temporary fading of pigmentation. I acknowledge that this treatment may not be given, if my skin has excessive acne, lesions, moles, or skin tags. The esthetician may recommend a different treatment plan. I acknowledge Dermaplane treatment is not an exact science and that no specific guarantees can or have been made concerning the expected result. *
Initial
I understand Dermaplane is a form of manual exfoliation using an esthetician grade, sterile blade which is mildly abrasive to gently remove dead skin cells from the epidermis. It also temporarily removes fine vellus, leaving a smooth surface. Therefore, I will follow the explicit after care instructions of my skincare therapist. *
Initial
I understand that if I add glycolic or other chemical peel solutions onto my Dermaplane that I may achieve greater results, but I will also assume greater risks and have discussed these risks with my skincare therapist.*
Initial
I acknowledge that the success of my treatment depends on me and I have an obligation to follow the written and spoken instructions concerning pre and post treatment care in order to achieve optimal results. *
Initial
Should be Empty:

Facial Questionnaire & Consent

Your Medical History

Females Clients

Dermaplane Consent