Pretty Please Haus of Vanity

Skincare Facial Consent Form
Today’s Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who were you referred by?
Your Medical History
YesNo
Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
AsprinLatexFruitsShellfishFragrance/essential oilsTree NutsDairySunscreenNoneOther
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
YesNo
LowMediumHighNone
Your Skin
What are your skin concerns?
Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
YesNo
YesNo
Waxing/sugaringThreadingLaser/Electrolysis
AccutaneRetin-APrescribed topical cream
AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
YES, within the last monthYES, over a 2 months agoNO
Wear contact lensesHave a pacemakerHave metal implantsFrequent tanning beds
Females Clients
YesNo
YesNo
I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation.
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity, depedning on the treatment.

I acknowledge that if I fail to use a minimal sunscreen after a treatment (SPF 30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.

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 at least 3 days after 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

I release Ashly Valdez of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Signature
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Skincare Facial Consent Form

Your Medical History

Your Skin

Females Clients