Skincare Facial Consent Form

La Belle Esthetics

Facial Consent Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
How did you hear about us?
If referred, by who?
Your Medical History

Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess tour skin care needs.
Are you currently under the care of a physician?
Have you experiences any of these health conditions in the past or present?

Other
Any known allergies?

Other
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Have you ever experiences claustrophobia?
Please rate your stress level
Your Skin:
On scale 1 to 10 (1 = Horrible, 10 = Fantastic), please rate how you feel about the overall look of your skin.?
What are your skin concerns?
What is your ethnic background?
How often do you wear facial sunscreen?
If you go in the sun without sunscreen, how often will you burn??
What would you say your skin type is?
What skin care products do you use on a daily basis?
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?
Females Clients
Are you taking birth control?
Are you pregnant or breast-feeding?
Cancellation/No-Show POLICY:

• Recognizing that everyone’s time is valuable. We ask that you provide a 48 hr notice if you are unable to keep your appointment.

• Any cancelations or rescheduling with less than 48 hours notice, will be charged 50% of the service price.
If payment is not received due to cancelation/reschedule you must pay invoice prior to booking another appointment.
All “NO-SHOWS” will be charged 100% of the service price.

• La Belle Esthetics reserves the right to charge the appropriate amount of the service booked for any appointment that is not canceled within the 48 hrs advance notice.

• 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 content to “before and after” photo/videos for the purpose of documentation, potential advertising and promotional purposes.
Signature
Should be Empty:

La Belle Esthetics

Your Medical History

Your Skin:

Females Clients