3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
(682) 213-0798
lealux.glossgenius.com
Facial Consent Form
Client Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Medical Information
Do you have any of the following conditions? They may determine that you are not suitable for facial procedure.
Active infection of any type, such as Herpes simplex virus or flat warts.
*
Yes
No
Eczema
*
Yes
No
Dermatitis
*
Yes
No
Rosacea
*
Yes
No
Family history of hypertrophic scarring or keloid formation
*
Yes
No
Telangiectasia/erythema may be worsened or brought out by skin exfoliation
*
Yes
No
Facial hair removal in the past 7 days
*
Yes
No
Botox, Restylene, Juvederm, or any other filler in the last 72 hours
*
Yes
No
Chemical peel, laser service, or microdermabrasion within the last 6 weeks
*
Yes
No
Pacemaker
*
Yes
No
Metal implants/braces
*
Yes
No
Pregnant or breast-feeding
*
Yes
No
Recent use of topical agents such as glycolic acids, alphahydroxy acids and Retin-A
*
Yes
No
Use of Acutane within the last year
*
Yes
No
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Consent
Please check each box to show your understanding and agreement.
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Signature
This agreement will remain in effect for this procedure and all future facial procedures. I will alert the skincare specialist if there are any future changes to my medical history. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the facial procedure.
Signature
*
A copy of this signed agreement will be emailed to you.
Submit
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