Future You Skin Consent & Consultation Form

Future You Skin Consent & Consultation Form

I can't wait to meet you!
Todays Date*

MonthDayYear
Date
Date of Birth *

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

Walked byFacebook/InstagramOnline SearchFamily or friend referralSola professionalBarre3Spenga
If referred, by who?
What is your occupation?*
Your Medical History
Are you currently under the care of a physician?*

YesNo
Have you experiences any of these health conditions in the past or present?*

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesStaph Infection/ MRSAThyroid ProblemHysterectomyAnemiaNoneOther
If Yes to any, please explain
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneSulfurOther
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?*

YesNo
YOUR SKIN

Below will give me a better idea of how I can help you & make sure we are a good fit!
What is the most important part of our time with me?

I'm here to learn how to take care of my skin & find a solution to my problem.I'm here to relax, but I'm also interested in correcting issues I have with my skin.I'm strictly here to relax & unwind.
Tell me a little bit about what your goals are with your skin? What have you tried? What should I know about you/ your skin?*
What would you say your skin type is?*

Very Dry(pore size is extremely small, may get oily on nose, never feels oily after cleansing)Dry( Pore size is small, may get oily on nose, chin, and middle of forehead, may feel oily 10 to 12 hours after cleansing)Normal( Pore size is medium, may feel oily in T-zone, may feel oily 7 to 9 hours after cleansing)Oily( Pores are enlarged, oily in T-zone out to middle of cheeks may feel oily 4 to 6 hours after cleansing)Very Oily( Pore size is extremely large, oily all over face, feels oily 1 to 3 hours after cleansing)Impaired Barrier/ dehydrated ( Dry/ scaly skin, rough or discolored patches, sensitive or inflamed areas, itchiness, sudden/ abnormal breakouts)
Select all that apply for your skin*

Breakouts/ AcneExcessive oil/shineRosaceaBroken capillariesRednessSun spotsHyperpigmentationUneven skin toneSun damageTextureWrinkles/fine linesDullnessDry skinFlaky skinDehydrated skinDark circlesLack of elasticityPuffy eyes
Do you experience routine breakouts or acne?*

YesNoHormonal BreakoutsOther
Acne Type*

No visible blemishesInflamed Acne( cysts, nodules, pimples)Non-Inflamed Acne( Blackheads and/ or whiteheads)Combination of inflamed and non-inflamed acne( Blackheads, whiteheads, pimples, cysts, nodules)
Which of the following best describes your complexion?*

Fitz 1-very light or freckled, creamy complexion, Burns very easily, never tansFitz 2-Light complexion, burns easily, tans slightlyFitz 3- Light to olive, light/Matte complexion, burns moderately, tans graduallyFitz 4-Matte complexion, seldom burns, always tans wellFitz 5-Brown complexion, rarely burns, deep tanFitz 6- Dark brown, brown complexion, never burns, deeply pigmented
Have you ever been diagnosed with eczema, psoriasis or rosacea?*

YesNo
Do you blush easily?

YesNo
If Yes, what are the contributing factors?

EmotionsFoodTemperature ChangeOther
What skin care products do you use on a daily basis?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)ScrubVitamin CBenzoyl PeroxideEyelash serumEyebrow serum
Do you currently use:

AccutaneRetin-APrescribed topical cream or wash
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
What is your Ideal Skincare routine?

Only using 1-3 products Morning & NightUsing 3-5 products Moring & NightUp to 5 Products, Maybe a face mask or at home treatment once a weekGive me anything & everything
Would you like me to talk with you about products I recommend for your skin?

Yes, I am interested in learning about any products you recommend for me!Maybe give me your top 3 products you recommend.No, I wouldn't like you to recommend any products.
Have you had a facial treatment in the past?

YesNo
What was your experience?
Have you ever received chemical peels, laser services, Dermaplane, microdermabrasion treatments, or skin cancer removal?*

YESNO
If Yes, please specify
Have you ever had any negative reaction to products or treatments in the past? If yes, please list products or treatments.
Lifestyle & Diet
Please rate your stress level.*

LowMediumHighNone
Do you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeFrequent tanning bedsTanning Outside
Diet, Do you consume any of these items 3x or more a week?*

AlcoholCaffeineDairySoy productsPeanuts/ peanut butterProcessed foodFast foodSushiKelp/ seaweedMisoVitaminsSeafoodWhey or soy proteinNone
Do you normally sleep well?

YesNo
Do you exercise?

YesNo
Do you have any food intolerances?

YesNo
If yes, explain
How many glasses of water do you consume daily?
How many cups of caffeine-type beverage (coffee, tea, soft drinks, energy drinks) do you consume daily?

None1-3 Cups4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your diet or lifestyle; would that be okay with you?

YesNo
Females Clients
Are you taking birth control?*

YesNo
Are you pregnant or breast-feeding?*

YesNo
Any other comments, questions, or concerns please explain here!
Future You Skin Policies

Please read all information below!
I acknowledge that I must adhere to all of Future You Skin polices. I understand that cancellations must be done with at least 48 hours notice Failure to do so will result in the loss of a package or 25% 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 understand that pictures and/ or videos will be taken for tracking progress. These pictures and/ or videos may be posted on social media and used for marketing/research.
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I 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 (SPF28), 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

I release Future You Skin and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

I understand that to achieve my goals for my skin I must purchase all recommend home care and come in for regular treatments recommended for me by Future You Skin. I also understand that if I DO NOT purchase the recommend home care I will not be able to recieve treatment.
I Your full name do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I am also aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that i may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional Madison Frizzell and/ or Lauren Jaeger, Future You Skin and the staff harmless from any liability for adverse reactions that my result from any treatment performed by anyone at Future You Skin in the past, present, and future.
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Future You Skin Consent & Consultation Form

Your Medical History

YOUR SKIN

Lifestyle & Diet

Females Clients

Future You Skin Policies