• New Client Consultation/ Consent Form

    Angela's Esthetics LLC
  • Date
     - -
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • What are your skin care challenges? (check all that apply)
  • Have you ever had a facial or skin treatment before?

  • If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT, TYPE &NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals. 

  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
  • Have you received any of these facial hair removal services in the last 30 days?
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?
  • Have you received any Botox, Juvaderm, or other dermal fillers in the last 2 weeks?

  • Health

  • Have you experienced any of these health conditions in the past or present?
  • Do you ?
  • Do you take any of the following dietary/ health supplements?
  • Any known allergies?
  • Have you used or beem prescribed any medications (topical or oral) for acne/ acne control?
  • Are you a smoker?
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
  • Have you ever experienced claustrophobia?
  • Please rate your stress level?

  • Female Clients

  • Are you taking birth control?
  • Are you pregnant or trying to become pregnant?
  • Any menopause issues?
  • Are you undergoing any hormone replacement therapy?

  • I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. I understand all pre/post treatment instructions and I understand the importance of following the instructions given to me. I hereby consent to any treatments offered at Angela's Esthetics (Chemical Peels, Dermaplaning, Hydrofacials, Microdermabrasion, Microneedling, Waxing, Circadia Enzyme Therapy, & all other treatments offered at Angela's Esthetics). Although it is impossible to list every potential risk and complication, I understand that there are risks, benefits and complications associated with any/all treatments. I understand that Angela's Esthetics will not be held liable for any complications, reactions, or side effects that may occur and I am agreeing to undergo all treatments provided by Angela's Esthetics at my own risk.

     

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