Client Consultation Consent Form
Date of birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Please take a moment to answer the following questions
What brings you in today? What is your main concern relating to your skin?
Are you presently taking any medications?
Are you pregnant?
Do you have any allergies to cosmetics, food or drug?
What skin care products do you currently use?
Vitamin C Serum
Please specify if there are any other concerns you may have?
Have you had skin cancer?
Do you use acne medication?
Are you taking oral contraceptives?
Please check if you are affected by or have any of the following
I agree with If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. Also I understand that; The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future
Are you a minor (under the age of 17)?
Parent's Signature (if client is a minor)
Should be Empty: