Facial Consent Form

Facial Consent Form

Esthetics With Me
Date*

MonthDayYear
Date
Name*
First & Last Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Occupation
How did you hear about us?*
If referred, by who?
Do you have instagram?

YesNo
Lets connect! What's your instagram handle?
Have you had a Facial Treatment before?
How was your facial experience? What was your favorite part?
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you experienced any of these health conditions?*

ArthritisAsthmaAuto-immune DisorderCancer/ Systemic diseaseCold soresDepressionDepression/AnxietyDiabetesEczemaEpliepsy/SeizuresHeadaches/ MigranesHeart conditionHepititisHigh Blood PressureHIV/AIDSHormone ImbalanceHyper/Hypo ThyroidHyperpigmentationHypo PigmentationInsomniaLow Blood pressureLupusPregnantPsoriasisRashesSeborrheaShinglesSinus InfectionSkin CancerSurgeries in the last yearWarts (hands or face)None
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySulfurGlutenNoneOther
List medications/supplements you are currently taking.
How much water do you drink daily?
Have you ever received any botox or fillers? if so, where and when?
Have you ever experiences claustrophobia?

YESNO
Please rate your stress level

LowMediumHighNone
Your Skin
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to products, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
What concerns to you have regarding your skin? Select all that apply

Acne/breakoutsBlackheads/whiteheadsBroken capillariesClogged poresDark spotsDrynessExcessive oil/shineRednessRosaceaScarringSun damageUneven skin toneUnwanted hairWrinkles/fine linesOther
What are your biggest concerns in your own words?
What are you happy about with your skin?
Does your skin (face or body) feel itchy?

YesNoSometimes
What is itchy? Any known reason why?
What skin care products do you use on a daily basis?*

Cleanser - creamCleanser - foamCleanser - gelBody SoapSerumTonerMaskEye CreamSPFPhysical ExfoliantVitamin A (retinol)Moisturizer - creamMoisturizer - gelOther
What product lines do you use & what are your skincare steps? Use this Box for AM Routine:
Use this box for your PM Routine:
What do you think your current skincare is missing?
Do you experience routine breakouts or acne?

YESNO
If Yes: Where are your breakouts?
Take Photo
**If unavailable to take a photo of makeup while filling out this form - please take picture(s) of makeup before arriving for your treatment to show your esthetician.
Have you been diagnosed with eczema, psoriasis or rosacea?

EczemaPsoriasisRosaceaNo
If yes: Where on your body have you been diagnosed?
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Do you currently use:

AccutaneRetin-APrescribed topical creamNone of the above
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retinoids)Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Do you?

Wear contact lensesHistory of SeizuresHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning bedsHistory of Heart Issues
Females Clients
Are you taking birth control?

YESNO
Which birth control?
Are you pregnant or breast-feeding?

YESNO
I acknowledge that I must adhere to Esthetics With Me policies. I understand that cancellations must be done with at least 48 hours notice. Any cancelations within less than 48 hours of notice are subject to a cancelation fee amounting to 50% of your scheduled service. Clients who miss their appointments without giving any prior notification will be charged in full for the scheduled service. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.
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 (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. 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 5 days 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 have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I give consent for all future treatments I release Esthetics With Me and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
First & Last Name
Signature

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Facial Consent Form

Your Medical History

Your Skin

Females Clients