Skin By Lindsay Minor Consultation Form

1

Parent’s Name

First Name

Last Name

2

Parent’s Phone Number

Please enter a valid phone number.

3

Child’s Name

First Name

Last Name

4

DateToday’s Date

Date

5

Child’s Date of Birth

Date

6

Does your child have any allergies?Please list below

7

Is your child currently using Accutane or has used Accutane within the past year?

YESNO

8

Is your child currently using prescription acne medication?

YESNO

9

Is your child currently under a doctor’s care for: cancer, autoimmune disorder, skin disorder, epilepsy, or any other condition that could possibly be impacted by receiving esthetic services?

YESNO

10

Do you consent for your child to receive the chosen esthetic services?

YESNO

11

Do you promise to inform your child to let their esthetician know if they experience any pain, discomfort, or a medical emergency during services, so that they can be stopped immediately and parent informed?

YESNO

12

Parent’s Signature