Facial Consent Form
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
How did you hear about us?
*
Walked by
Facebook/Instagram
Online Search
Referral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?
*
YES
NO
Have you experienced 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
Any known allergies?
*
Asprin
Latex
Fruits
Shellfish
Lidocane
Fragrance/essential oils
Tree Nuts
Dairy
Sunscreen
Pollen
None
Other
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Have you ever experienced claustrophobia?
YES
NO
Please rate your stress level
Low
Medium
High
None
Your Skin
What are your skin concerns?
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)
What skin care products do you use on a daily basis?
*
Soap
Cleanser
Toner
Serum
Mask
Exfoliant (physical or chemical)
Eye Cream
Moisturizer
SPF
Vitamin A (retinol)
Do you experience any breakouts or acne?
YES
NO
Have you been diagnosed with eczema, psoriasis or rosacea?
YES
NO
Have you received any of these facial hair removal services in the last 7 days?
Waxing/sugaring
Threading
Laser/Electrolysis
Do you currently use:
Accutane
Retin-A
Prescribed topical cream
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/retonids)
Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
YES, within the last month
YES, within the last 2-3 months
NO
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Smoke
Consume Alcohol
Consume Caffeine
Frequent tanning beds
Females Clients
Are you taking birth control?
YES
NO
Are you pregnant or breast-feeding?
YES
NO
I authorize Haus of Remedy to perform this procedure. I have indicated that I have no conditions that would negatively effect the outcome of my service.
I release Haus of Remedy for any responsibility in case of an accident, illness, or injury.
I authorize Haus of Remedy the right to take, edit, alter, copy, exhibit, and make use of any and all pictures, video, and or audio taken of me to be used for promotional purposes on all social media platforms.
I acknowledge that all information I provided in this form is true and accurate.
Signature
Submit
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