Pretty Please Haus of Vanity

Today’s Date

Date

Date of Birth

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?

Are you currently under the care of a physician or dermatologist?

Have you experienced any of these health conditions in the past or present?

Any known allergies?

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.

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 42 hours?

Do you currently use:

Are you currently using any products that contain:

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Do you?

Are you pregnant or trying to be?

Are you breastfeeding?

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

Skincare Facial Consent Form

Your Medical History

Your Skin

Females Clients