Skin By Lindsay Consultation and Consent Form

1

Date

2

Name

First Name

Last Name

3

Birthdate

Date

4

Phone Number

Please enter a valid phone number.

5

Email

example@example.com

6

Emergency Contact

Name

Phone number

Relationship to client

8

Are you taking any medications that can affect the skin?Birth control and antibiotics are common ones

9

AccutaneAre you currently being treated or have been treated in the past year with Accutane?

YESNO

10

Prescription RetinoidAre you currently using or have used in the last two weeks, a prescription retinoid such as tretinoin/Retin-A/Renova?

YESNO

11

AllergiesDo you have any known allergies? If no, type “no” below.

12

Do you give Lindsay Pritchard DBA Skin By Lindsay consent to perform your chosen services both today and for future booked appointments?

YESNO

13

Do you affirm that you are consenting to any services you have booked and will book with Skin By Lindsay in the future, of your own free will and at your own risk?

YESNO

14

Do you affirm that you will inform Lindsay Pritchard DBA Skin By Lindsay of any discomfort, pain, or medical emergency during your services, so that she can stop services immediately?

YESNO

15

SignaturePlease Sign Below