Skin Health with Mel - Facial Consent Form

Facial Consent Form / First Time Client
Date

MonthDayYear
Today’s Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
How did you hear about us? -

Other
If referred, by who?
Music preference

Other
During your appointment do you prefer
Your Medical History
Are you currently under the care of a physician?
Have you experiences any of these health conditions in the past or present?

Other
Please list any allergies, if any.
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? If yes, where was it put and how long ago?Please wait at least two weeks after your injections to get a facial.
Have you ever experienced claustrophobia?
Please rate your stress level
Your Skin
What are your skin concerns?
What would you say your skin type is? (You can select more than one.)
What skin care products do you use on a daily basis?
Do you experience routine breakouts or acne?
Have you been diagnosed with eczema, psoriasis or rosacea?
Have you received any of these facial hair removal services in the last 7 days?
Do you currently use:
Are you currently using any products that contain:
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Do you?
Please stop any active ingredients 3-5 days before your appointment. This includes retinols, AHA (glycolic, mandelic, lactic acids), BHA (salicylic acid), or physical exfoliants.

Message me a photo of your products if you’re unsure.
Females Clients
Are you taking birth control?
Are you pregnant or breast-feeding?
Treatment Consent and Liability Waiver:
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended home regimen for a few days following treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Skin Health with Mel and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Please read cancellation policy below:
I acknowledge that I must adhere to Skin Health with Mel’s policies. I understand that cancellations require at least 24 hours’ notice. Failure to do so will result in a charge of 50% of the total service cost. A second late cancellation within 24 hours will also result in a 50% charge and a deposit will be required for future appointments. I acknowledge that any no-show will result in the loss of a package or a charge of 100% of the service cost. I understand that if I am more than 15 minutes late, my appointment may be subject to cancellation and I will be held responsible in accordance with the no-show policy.
Photo Release: I grant permission for Skin Health with Mel to take/use photos or videos taken during my service for social media purposes (e.g. Instagram, Facebook, website etc.).
Signature
Minor Policy: To maintain a safe and relaxing environment, minors are not permitted unless they are being serviced.
If client is a minor, please fill out: Parental/Guardian Consent for Minor Services Required for clients under 18 years of age. I, the undersigned, am the parent/legal guardian of the minor named below. I hereby give my consent for Skin Health with Mel LLC to perform the requested service(s) on my minor child. I understand the nature of the service(s) being provided and acknowledge that I have been informed about any potential risks or side effects. I affirm that I have read and understood the information provided in this consent form and agree to its terms.
Parent/Guardian

First NameLast Name
Optional: Please list which modalities you’re interest in for your facial. Advanced modalities may include Dermaplaning (fill out dermaplaning form), Microdermabrasion, CO2 Carboxy Therapy, HydroJelly Mask with neck/shoulder massage, hand mask with heated mitts and hand massage, LED therapy, or light chemical peel. (This does not apply to The Flow Facial.)
Learn more about the modalities here: Modalities
Please list anything you’d like for me to know before your appointment.
Should be Empty:

Facial Consent Form / First Time Client

Your Medical History

Your Skin

Please stop any active ingredients 3-5 days before your appointment. This includes retinols, AHA (glycolic, mandelic, lactic acids), BHA (salicylic acid), or physical exfoliants.

Females Clients

Treatment Consent and Liability Waiver:

Please read cancellation policy below:

Minor Policy: To maintain a safe and relaxing environment, minors are not permitted unless they are being serviced.