Facial & Dermaplane Consent Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which form of contact do you prefer?
Text
Email
Can I take photos of your skin for advertisement purposes?
Yes
No
Do you have any allergies? Please list any, including food and medications
Are you on any medication? If so, please list.
Are you on any prescribed topical creams? If so, please list.
Have you ever been treated for cancer? If so, please list when your treatment ended. (Treatments can compromise the skin)
Do you have epilepsy or are prone to seizures?
Yes
No
Do you easily feel claustrophobic?
Yes
No
Do you have any metal implants?
Yes
No
How did you hear about Southern Beauty Skin?
What do you feel your skin type is?
Dry
Oily
Combination
Sensitive
Flaky
Which of the following best describes your skin?
Type I - Fair, easily burns, never tans, sensitive
Type II - Light skin tone, sometimes tans
Type III - Olive skin tone, always tans
Type IIII - Darker skin tone, sensitive
What skincare concerns do you have? Check all that apply
Dryness
Sensitivity
Redness
Acne
Oily skin
Pigmentation
Scarring
Fine lines/wrinkles
Overall aging
What are you skincare goals?
What skincare products are you currently using?
Do you wear makeup? If so, how often.
Are you currently using any retinols? OTC or prescribed.
Are you prescribed Accutane? (An oral acne medication)
Yes
No
I have been in the last year
Do you tan or use the tanning bed often?
Yes
No
Do you spend a lot of time in the sun?
Yes
No
Do you work out/sweat/get hot often?
Yes
No
What is your stress level? (1 being mild 5 being very)
1
2
3
4
5
Do you feel like your stress level affects your skin?
Yes
No
Is there anything else you’d like to tell me?
I understand that all charges on my bank statements will show up as Gloss Genius
Yes
Dermaplane Inform and Liability Form. Please check off to confirm you've read, understand and agree.
I understand that dermaplaning is an exfoliation service that uses a sterile one time use blade to remove 3-4 weeks of dead skin and peach fuzz (vellus hair) that creates 2-3x better product penetration, has no down time, lightens and brightens, and provides anti-aging benefits., I understand that dermaplaning utilizes a sterile blade and there is a chance of nicks or cuts to the skin, even though all precautions are always taken. By checking this box you are consenting to this service., I understand that some medications including but not limited to blood thinners, high doses of Aspirin are contraindications for this treatment due to increased sensitivity and/or a higher possibility of nicking/delaying blood clotting., I certify that I'm not taking any of these medications or substitutes for these medications.
General Facial Consent and Liability Form. Please check off to confirm you've read, understand and agree.
I have read and complete this questionnaire truthfully and to my best ability. I understand that withholding information and/or providing misinformation could result in irritations/reactions to the skin from treatments received. The treatments I receive are voluntary and I release Savannah Grizzaffe and Southern Beauty Skin from any liability., I consent that the answers provided are the truth and correct. I consent that I have not withheld any information that may be relevant to my treatment(s). I consent to all future services/treatments/appointments.
Cancellation/No show, Late and Child Policy. Please check off to confirm you've read, understand and agree.
I kindly ask for at least 24 hours notice for cancellations to respect my time and others that may be looking to get in for a service. If you cancel after the 24 hour mark, 30% of your grand total will be charged to the card on file. Please reach out to let me know your situation! Life happens, we're human and I completely understand. With that being said, I must also protect myself and my business. Thank you for understanding!, If you are to no call/no show your appointment, 30% of your grand total will be charged to the card on file and you will need to pay a $25 deposit via invoice before your next appointment will be approved. Invoice will be sent via email., Late Policy - I do allow a 10 minute grace period, accidents/construction/kids/doggie accidents (or doggie's just WON'T come inside....) happen! However, your appointment will still end at the original end time (Ex: you have a 1pm appointment, you're 10 minutes late, the appointment still ends at 2pm) If you are more than 10 minutes late we will have to reschedule., First Time Clients - Please arrive 5-10 minutes early to go over any questions you may have and go over our current skincare products! Please bring a list or a photo of your current routine., Child Policy - I unfortunately cannot have children under the age of 10 in my studio due to insurance purposes. Thank you for understanding! Let's make this treatment all about you!
Signature
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