Facial Consent Form

New Client Consent Form

Please fill out completely
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
How do you prefer to be contacted?*

Phone CallText
How did you hear about us?
Have you had a facial before?*

YESNO
Have you ever had any issues with your previous facials?*

YESNO
If so, what were the issues?*

Break outsReactionOther
Have you used any hair removal methods in the past six weeks? (Check all that apply)*

WaxingLaserPluckingThreadingElectrolysisDepilatoriesNone
Which of the following best describes your skin type? (Please check one)?*

Type I (Fair skin tones-Always burns, never tans)Type II (Light skin tones-Burns easily, tans slightly)Type III (Fair to olive skin tones-Burns moderately, tans moderately)Type IV (Light brown skin ones Burns slightly, tans easily)Type V (Dark brown skin tones Rarely burns, tans easily)Type VI (Dark brown to black skin tones-Never burns, tans easily)
Have you ever had chemicals peels, laser treatments, or microdermabrasion? If so, please list it.*
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products? If so, please list it all.*
What skin care products are you currently using? (Lists brands if known)*
What are your specific skincare concerns?*

Dry Flakey SkinBreakoutsWrinklesBlackheadsAcneLoss of FirmnessClogged PoresSkin TextureLarge PoresHyper-Pigmentation / Uneven Skin ToneRednessSkin SensitivityRosaceaOily SkinMiliaFine LinesNone of the aboveNone of the aboveOther
What brings you in for a facial?*

Skincare EducationAcne ConcernMature exfoliationOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
What is the skincare brand you use?*

I don't use skincareOther
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescriptive creams or meds for skin?
Do you currently have any rashes, itching or underlying redness on your face?*

YESNO
Have you ever received any botox or fillers? if so, what location on your face and when? *
Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Your Medical History
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNoneOther
Please list medications or supplements you are currently taking.*
Medications or supplements
Have you ever experienced claustrophobia?*

YESNO
Have you ever experiences vertigo or issues laying flat?*

YESNO
Have you experiences any of these health conditions in the past or present?*

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
What would you like to achieve from your treatment?
Females Clients
Are you taking birth control?*

YESNO
Are you pregnant or breast-feeding?*

YESNO
I authorize and grant DangSkyn to take my photos regarding my experiences with them. I grant DANGSKYN Beauty to use my photos on Facebook, Twitter, Instagram, and other social media platforms. I allow DangSkyn beauty to edit, alter, copy, or distribute the photos for social media advertising and marketing. I agree that the photos belong to DangSkyn, and I understand that I will not receive any monetary compensation
Initial
Acknowledgement and Waiver I hereby agree to have this treatment.

I am aware that products used in facials and homecare may contain tree nuts, sulfur, dairy, and gluten.

I acknowledge that the estheticians at DangSkyn may use products that contain these ingredients or are manufactured in a plant with these ingredients.

I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. Please inform your esthetican before treatment if severly allergic, as this may make you unable to receive the service.

I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form and agree to update DangSkyn as to any changes.

It is my responsibiliy to disclose all medical, medicinal, and skin history, as DangSkyn will not be responsible to reactions caused by undisclosed medical history.

I acknowledge the esthetician at DangSkyn do not provide medical advice and

I accept full responsibility to seek out advice before receiving any services or products from DangSkyn.

I hereby release, discharge and waive all claims against DangSkyn and each of their employees, and representatives or any person(s) performing services or applying any products at DangSkyn, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates.

I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
Signature*
Date*

MonthDayYear
Date
Dermaplane Consent
I acknowledge and understand while the goal of this treatment is superficial exfoliation and removal of vellus hair (peach fuzz), I may receive added improvements such as reduction in the appearance of fine lines & temporary fading of pigmentation. I acknowledge that this treatment may not be given, if my skin has excessive acne, lesions, moles, or skin tags. The esthetician will work around bumps, but if the skin was too many, the esthetician at DangSkyn may recommend a different treatment plan. I acknowledge Dermaplane treatment is not an exact science and that no specific guarantees can or have been made concerning the expected result. *
Initial
I understand Dermaplane is a form of manual exfoliation using an esthetician grade, sterile blade which is mildly abrasive to gently “shave off” dead skin cells from the epidermis. It also temporarily removes fine vellus, leaving a smooth surface. Therefore, I will follow the explicit after care instructions of my skincare therapist. *
Initial
I understand that if I add glycolic or other chemical peel solutions onto my Dermaplane that I may achieve greater results, but I will also assume greater risks and have discussed these risks with my skincare therapist.*
Initial
I acknowledge that the success of my treatment depends on me and I have an obligation to follow the written and spoken instructions concerning pre and post treatment care in order to achieve optimal results. *
Initial
Date*

MonthDayYear
Date
COVID-19 Liability Waiver
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that DangSkyn has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that DangSkyn can not guarantee that I will not become infected with the Coronavirus/Covid-19.

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.

I voluntarily seek services provided by DangSkyn and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.

I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I attest that:

* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I have not traveled internationally within the last 14 days.

* I have not traveled to a highly impacted area within the United States of America in the last 14 days.

* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.

* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree to hold DangSkyn harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from DangSkyn.

I understand that this release discharges DangSkyn from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from DangSkyn.

This liability waiver and release extends to the salon together with all owners, partners, and employees.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Client Consent Form

Your Medical History

Females Clients

Dermaplane Consent

COVID-19 Liability Waiver