Back Facial
Consent Form
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Your Medical History
Any known allergies?
*
Latex
Fruits
Fragrance/essential oils
Tree Nuts
Sunscreen
None
Other
List medications/supplements you are currently taking.
Please rate your stress level
Low
Medium
High
None
Your Skin
Reason for visit
*
Do you experience back breakouts or acne?
*
YES
NO
Have you been diagnosed with eczema, psoriasis or rosacea?
*
YES
NO
Type a question
*
I AGREE THAT A 48 HOUR NOTIFICATION IS REQUIRED TO AVOID A $50 CANCELLATION FEE OR A $50 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
Signature
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