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FACIAL CONSENT FORM
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28
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1
Date
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Date
Month
Day
Year
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2
Name
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First Name
Last Name
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3
Date of Birth
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Day
Year
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4
Email
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example@example.com
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5
Phone Number
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Area Code
Phone Number
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6
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
Have you experiences any of these health conditions in the past or present?
Hormone Imbalance
Cancer/ Systemic disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-immune Disorder
Asthma
Epliepsy/Seizures
Cold sores
HIV/AIDS
Lupus
Depression/Anxiety
Headaches/ Migranes
None
Other
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8
Any known allergies?
*
This field is required.
Asprin
Latex
Fruits
Shellfish
Lidocane
Fragrance/essential oils
Tree Nuts
Dairy
Sunscreen
Pollen
None
Other
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9
List medications/supplements you are currently taking.
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10
Have you ever received any botox or fillers the last 4 weeks? If so, where and when?
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11
What are your skin concerns?
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12
What would you say your skin type is?
Normal (no visible blemishes, fine pores, smooth texture)
Sensitive (reactive to fragrance, 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)
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13
Do you experience routine breakouts or acne?
YES
NO
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14
Have you been diagnosed with eczema, psoriasis or rosacea?
YES
NO
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15
Have you received any of these facial hair removal services in the last 7 days?
Waxing/sugaring
Threading
Laser/Electrolysis
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16
Do you currently use:
Accutane
Retin-A
Prescribed topical cream
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17
Are you currently using any products that contain:
AHA (glycolic acid, lactic acid, etc.)
BHA (salicylic acid)
Vitamin A derivative (retinol/retonids)
Exfoliating scrubs
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18
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
YES, within the last month
YES, within the last 2-3 months
NO
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19
Do you?
Have metal implants
Smoke
Consume Alcohol
Consume Caffeine
Frequent tanning beds
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20
Pictures & videos will/could be taken for record keeping & advertising purposes. Do you consent?
Yes
No
Only for record keeping
Type option 4
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21
A few minutes of Hair Brushing & Scalp Stimulation is/could be included in the Facial. Do you consent?
Suggestion: Hair must be mostly untangled to avoid breakage and feeling uncomfortable
Yes
No
Other
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22
Are you taking birth control?
YES
NO
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23
Are you pregnant or breast-feeding?
YES
NO
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24
The Client understands that the number of Microneedling and Chemical Peel treatments required varies and that several treatments may be needed.
The Client understands that there may be some degree of discomfort, (i.e., scratchiness, itchiness, irritation, stinging and hotness.)
The Client understands that it is normal for the treated area to appear red with slight swelling after the treatment, similar to mild-moderate sunburn, which can last for up to 4 days following treatment. There may also be very mild temporary bruising.
The Client understands that this procedure does not come with any guarantees and understands in order to achieve maximum results, they will need maintenance treatments and the use of daily recommended products.
The Client understands that exposure of a recently treated area to direct sunlight should be avoided and that we advise the use of an SPF of 30 or higher.
The Client confirms that they have informed BellaBrow by Vera Esthetics of all their medical details relevant to this treatment and will inform BellaBrow by Vera Esthetics of any changes throughout the duration of the treatments should any information change.
The Client confirms that they have understood all the information given regarding this treatment during the consultation and that any questions that have been presented have been answered satisfactorily.
The Client understands that there are other treatment options available, including doing no treatment at all.
The Client acknowledges that they have read and fully understood this document before signing.
The Client releases BellaBrow by Vera Esthetics of any and all liability.
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25
I acknowledge that I must adhere to BellaBrow by Vera Esthetics' policies.
I understand that deposits are non refundable.
I understand that in order for my deposit to be transferable, I must give a 2 week 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.
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26
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 (SPF 30), 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 2-4 weeks 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 give consent for all future treatments.
I release BellaBrow by Vera Esthetics LLC and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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27
By signing the next screen I am agreeing to all policies mentioned above:
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28
Signature
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