New Client Facial Consent Form

Name*

First NameLast Name

Date Of Birth 00/00/00*

Cell Number *

Please enter a valid phone number.Format: (000) 000-0000.

Ok to Text?*

Email*

example@example.com

How Did you find out about Pretty Tingz? *

What treatment are you receiving? *

Do you have ANY allergies to medications, foods, latex, or other substances? Please list:*

Do you Smoke? *

Do you have ANY current or chronic medical conditions? Disclose any history of heat rash/ hives, diabetes, autoimmune disorder or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness.*

If Yes, Please list, Please mark N/A if no..*

Do you have ANY current or chronic skin conditions? Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, skin cancer, or any other skin condition.*

If Yes, Please list, Please mark N/A if no..*

Do you currently see a dermatologist?*

Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?*

If so, for what? Please mark N/A if no..*

Skincare and makeup: (Select all that apply)*

Are there any topical medical products that you use on your skin on a regular or daily basis? *

If so, for what? Please mark N/A if no..*

Are you taking oral steroids (eg. prednisone, dexamethasone)?*

Do you have a pacemaker or external defibrillator? *

Do you have any metal implants under the area being treated?*

Do you have a history of light-induced seizures?*

Do you have a history of Herpes in the area being treated?*

Do you have any open sores or lesions?*

Have you had radiation therapy in the area being treated?*

Do you have a history of keloid scaring or hypertrophic scar formation?*

In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?*

List Product, Date Used: Please mark N/A if no.*

In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?*

If so, for what? Please mark N/A if no.*

Have you had any cosmetic procedures in the past 6 months?*

If so, for what? Please mark N/A if no.*

Have you had any permanent make-up, tattoos, implants, or fillers, including: but not limited to collagen, autologous fat, Restylane, ect.?*

If yes, please list locations and dates. Please mark N/A if no.*

In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?*

If yes, please list locations and dates. Please mark N/A if no.*

Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?*

Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?*

Are you pregnant or breastfeeding?*

*

I hereby consent to and authorize Pretty Tingz By Pey to perform facial treatment.I have voluntarily elected to undergo this treatment after the nature and purpose have been explained to me, along with he risks and hazards involved, by Peyton Merringer.Although it is impossible To list every potential risk or complication, I have been informed of possible risks and benefits. I also recognize there are no guaranteed results and that independent results are dependent upon skin conditions, age, lifestyle and home care.I understand that there is the possibility I may require further treatment to the areas treated to obtain expected results, at an additional cost.I understand I am to follow post-treatment instructions given by my Esthetician. I understand how important it is to follow instructions given to me for post-treatment care. In the event that I may have additional questions regarding my treatment or suggested homecare, I will consult with my Esthetician immediately.I also understand that facials are not a substitute for a medical examination, diagnosis or treatment, and that I should refer to my physician for any ailment.I affirm that I have stated all of my known medical conditions and answered all questions honestly.I agree to keep Pretty Tingz By Pey updated of any changes in my medical profile, and that there will be no liability on Peyton Merringer or Pretty Tingz By Pey should I fail to do so.I do not consent to these terms

I release the rights to any photos taken before, during or after the procedure to be used for educational or marketing purposes.

I do not consentI consentI consent with these limitations

Example of limitation: no full face photos, no photos showing bottom half of face, or no open eye photos. Please list:

Date

Signature*

New Client Facial Consent Form

Please answer each of the following questions:

For Women Only

Consent