Facial Client Intake and Consent Form

Today's Date*

Date

Name*

First NameLast Name

How did you hear about Pasadena waxing Garden?*

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Any known allergies (check all that apply)?*

Please list any other allergies or sensitivities:

Are you currently using any products that contain or are you taking any of the following?*

Have you ever had an adverse reaction after using any skin care product?*

YesNo

If yes, please check all that apply:

If yes, which products or brands?

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following: I give my permission to receive Skincare Treatments services or Waxing services. I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications. I understand the risks associated with facials and waxing include, but are not limited to:• Superficial bruising or redness• Short-term muscle soreness• 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. I acknowledge that this treatment is strictly an 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 not part of the recommended take-home regimen for 2-4 weeks following skin treatment. I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risks based on my physical condition. I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly. I understand that I or the esthetician may terminate the session at anytime. I have been given a chance to ask questions about the session and my questions have been answered. 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 give consent for all future treatments.

Signature*

Medical History

Your Skin