Client Intake and Skincare Facial Consent Form

Client Intake and Skincare Facial Consent Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
If referred, by who?
Your Medical History
Are you currently under the care of a physician?
Have you experiences any of these health conditions in the past or present?

Other
Any known allergies? Mark all that apply

Other
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Have you ever experienced claustrophobia?
Please rate your stress level.
Your Skin
What are your skin concerns?
What would you say your skin type is?
What skin care products do you use on a daily basis?
Do you experience routine breakouts or acne?
Have you ever been diagnosed with eczema, psoriasis or rosacea?
Have you received any of these facial hair removal services in the last 7 days?
Do you currently use:
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Do you?
Females Clients
Are you taking birth control?
Are you pregnant or breast-feeding?
I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “No-show” policy.
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. Secondly, ifI am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments
Signature
Date

MonthDayYear
Date
Should be Empty:

Client Intake and Skincare Facial Consent Form

Your Medical History

Your Skin

Females Clients