Facial Consent Form

Date

Name

First NameLast Name

Date of Birth

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

How did you hear about me?

If referral, please list name

If other, please let me know

What are your skin care goals?

What is your skin type?

What are your skin care challenges?

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?

What skin care products do you currently use?

Cleanser/Face Wash

Face Scrub/Exfoliants

Toner

Serums

Moisturizer(s)

Sunscreen

Eye Product(s)

Lip Product(s)

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives? (Please keep in mind, if you have used ANY form of retinol in the last 7 days, you will not be able to get any facial service/chemical peel)

Please specify which product or type, if you answered ‘Yes, currently using’ to above.

Have you received any of these hair removal services in the last 7 days? (Please keep in mind, if you have received any of the services in the last 7 days, you will not be able to get any facial service/chemical peel)

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? (Please keep in mind, if you have received any of the services in the last 12 days, you will not be able to get any facial service/chemical peel)

Have you experienced any of these health conditions in the past or present?

If you checked yes to any of these please provide further information. If not mark n/a

Do you?

Do you take any of the following dietary/health supplements?

If other, please list

Any known allergies?

If other, please specify

Have you used or been prescribed any medications (topical or oral) for acne/acne control?

If yes please specify what and date last used

Are you a smoker?

Do you drink more than 4 caffeinated beverages a day? (Tea, coffee, soda, energy drinks)

Have you experienced claustrophobia?

Please rate your stress level

Are you taking birth control?

If yes, what kind

Are you pregnant or trying to become pregnant?

Any menopause issues?

If yes, please specify

Are you undergoing any hormone replacement therapy?

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.

What is your current shaving system?

Do you experience irritation from shaving?

Cancellation policy: In failure to cancel your appointment before the 48 hour mark will result in a $75 charge. No shows will also be charged $75 the first time. If a no show a second time full service charge will be taken.

Monthly VIP membership policy: I understand facial packages must be used on a monthly basis in order to get the discounted rate and only one month is waived if needed to cancel. Failure to follow package policy requires previous facials to be paid full price.

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.

I consent to the taking of photographs during the course of service for records.

I consent to using my photographs for marketing purposes. My name will not be used to identify these photographs.

Signature

Facial Consent Form

Your Skin

Your Health

Female Clients

Male Clients