Kairopractic Skin Facial Consent Form 2023
Consent forms must be completed on a yearly basis.
Full Name
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
How did you hear about Kairopractic Skin?
*
Instagram
Google
Yelp
Personal Referral
Other
What areas of concern do you have regarding your skin?
*
Acne/Breakouts
Blackheads/Whiteheads
Hyperpigmentation
Sun Damage
Excessive Oil Production
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Redness
Other
Have you been in the care of a dermatologist within the past year?
*
If yes, please explain.
Have you received Botox, Restylane, or Collagen injections in the last 12 days?
*
Yes
No
Are you currently using, or have you used topical/oral antibiotics, Retin-A, Renova, AHA or Retinol/Vitamin A derivative products?
*
If yes, please explain.
What type of exfoliant do you use?
*
When was the last time you exfoliated your face?
*
PHOTO CONSENT & RELEASE Kairopractic Skin asks for your permission to take pictures or videos of your service either before, after or during to be used to either track progress or post for promotional purposes.Do you give permission for your photos or videos to be used on Social Media platforms or for other marketing purposes? Check whichever box below you are consenting to:
*
Yes, I give permission for all photos and videos to be taken and shared.
I give consent to have phtos or videos taken. However, I wish for my identity to be concealed. (Blacked out eye areas or ask that imagery be taken from an angle to hide prominent facial features)
I only give permission for photos to be taken for private use, to track my treatment progress.
I wish to decline any photos or videos to be taken.
I have completed this form to the best of my ability, knowledge and agree to inform my Esthetician, Jennifer Picazo of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my Esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my Esthetician, Jennifer Picazo for any injury or damages incurred due to any misrepresentation of my health history. By also signing this form I agree to abide by Kairopractic Skin’s Booking Policies stated on the Booking app at the time of booking this appointment
*
I agree
I disagree and will decline the service(s)
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: