Facial Consent Form

Facial Consent Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
InstagramFacebookYelpReferralOther
If referral, please list name
If other, please let me know
Your Skin
What are your skin care goals?
OilyDryCombinationNormalSensitive
Wrinkles/Fine LinesHyperpigmentation/Sun DamageAcne/Acne ScarringRedness/RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
Cleanser/Face WashFace Scrub/ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)Other
Please type the brand and the name of each product that you use
Cleanser/Face Wash
Face Scrub/Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Yes, currently usingYes, but not within the last 7 daysNoNot sure
Please specify which product or type, if you answered ‘Yes, currently using’ to above.
WaxingSugaringThreadingElectrolysis/LaserDepilatory CreamShavingNone
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Hormone ImbalanceCancer/Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy/Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches/MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark n/a
Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not applicable
MultivitaminVitamin CVitamin D/D3ZincOmega 3/Fish OilB Complex/B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
AspirinTree nutsLatexDairyFruitsVegetablesShellfishIodineFragrances/Essential OilsOtherNone
If other, please specify
YesNo
If yes please specify what and date last used
YesNo
YesNo
YesNo
LowMediumHigh
Female Clients
YesNoN/a
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
YesNo
If yes, please specify
Post facial/chemical peel care instructions:

Aerobic exercise and/or vigorous physical activity should be avoided for 24 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Chemical peels can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. No working out for 3 days after your chemical peel. Limitation of the sun post peel. Make sure to apply spf, wear sun protection, and follow post chemical peel product instructions. No exfoliation/masking for 7 days post peel. Chemical peel is not done on pregnant or breastfeeding women.
Male Clients
Razor/Wet ShaveElectricN/A
YesNoN/A
I have read the post care instructions and agree to adhere to them.
I understand the cancellation policies at Skin Dream Lab and consent to my credit card on file being charged if I fail to give 48 hour notice for appointments.
Yes
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

Yes
Yes
Yes
Signature
Should be Empty:

Facial Consent Form

Your Skin

Your Health

Female Clients

Male Clients