Skin Care Consent Form

Skin Care Consent Form
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
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
In case of emergency contact (name & number):
How did you hear about us
If friend /client referral, please list name so they can get reward points
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you had a facial before?
What are your specific skin care concerns?

Other
What skin care products are you using at home?
Brand(s):
Are you pregnant, lactating or plan on becoming pregnant soon?
Are you diabetic?
Do you have any kind of active cancer?
List all known allergies (food, products, ingredients, medication, etc)
Have you ever had a reaction to skin care products or ingredients?
If yes, please explain
Are you using any prescribed exfoliants? (Retin-A, Differen, Renova, etc)
How often?
Are you under the care of a doctor for an auto immune disorder?
Are you currently taking any medication that could interfere with a facial treatment?
If yes, please explain
How many ounces of water do you drink daily?
On average, how many hours of sleep do you get each night?
On a scale of 1-10, what is your current stress level? (10 being highest)
Do you take vitamins / supplements?
I understand that redness, sensitivity, peeling or other reactions may occur from facial treatments. If I experience any 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 estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment. The treatments I receive here are voluntary and I release the Spa at Springfield / Dolce Medical Spa or skin care professional from liability and assume full responsibility thereof.
By typing my name below, I acknowledge this document.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: