Client Skin Consent Form

Name*

First NameLast Name

Birthdate*

MonthDayYear

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Todays Date*

Date

Are you currently using a chemical exfoliant such as Retin-A, Epiduo, Differin, Renova, or Accutane?*

YesNo

Do you have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.*

YesNo

Area of Concern - SKIN:*

	Major Concern	Minor Concern	Somewhat Concerned	Not a Concern
Breakouts/ Acne
Blackheads/ Whiteheads
Excessive Oil/ Shine
Rosacea
Broken Capillaries
Redness/ Ruddiness
Sun Spot/ Liver Spot/ Brown Spot
Uneven Skintone
Sun Damage
Wrinkles/ Fine Lines
Dull/ Dry Skin
Flaky Skin
Dehydrated Skin
Other

Areas of Concern - EYES:*

	Major Concern	Minor Concern	Somewhat Concerned	Not a Concern
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other

Areas of Concern - LIPS:*

	Major Concern	Minor Concern	Somewhat Concerned	Not a Concerned
Dehydrated
Dry/ Cracked Lips
Wrinkles/ Fine Lines

Have you ever had an allergic reaction to any of the following?*

	Yes	No
Cosmetics
Medicine
Food
Animals
Sunscreens
Pollen
Alpha Hydroxy Acids
Fragrance
Shellfish
Latex
Drugs
Other

If Other, please list:

DERMAPLANE

I understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face and provide light exfoliation. I understand that the treatment may involve the risk of complication or injury and freely assume those risks. Possible side effects of the treatment area can include mild redness, mild irritation, and dryness. Additionally, nicks to the skin can occur due to the sharp surgical blade. If a chemical peel is included with this treatment, I understand that the sensation and penetration of the peel will be enhanced. This may cause skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores, when virus is already present in the body.

CHEMICAL PEEL

I understand my Esthetician will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions. I understand that, very rarely, permanent damage occurs. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

WAXING

I have given an accurate account of any over the counter or prescription medications that may interfere with my waxing service, such as to Accutane, Retin-A, Differin, Renova, blood thinners, high antibiotic use, Retinol and alpha-hydroxy products. I understand that it is my responsibility to bring up any questionable products that I may be using. also understand that dry skin or regular skin sensitivity may cause irritation or tearing of the skin during a waxing service.

FACIALS

I understand that facial results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type, condition, degree of sun/environmental damage, pigmentation levels, or acne condition.

Do you grant permission for your esthetician to take photos to use for confidential charting purposes and/or social media marketing to promote skin care services?*

Yes, my esthetician can use my photos.No, my esthetician can not use my photos.

Signature*

Date Signed*

I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I acknowledge that am aware of the risks involved and give consent to receive skin care services from my Esthetician. I understand that my esthetician has the right to refuse services if a client arrives ill. This is to protect the client, staff, and Esthetician