Facial Treatment Consent Form

Facial Treatment Consent Form

The Babe Cave Beauty Bar
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
Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Your Medical History
YesNo
Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenFoodOther
If 'other' , 'fragrance' or 'food' was selected above please list any specific known allergies:
List medications/supplements you are currently taking:
Have you ever received any botox or fillers? if so, where and when?
YesNo
LowMediumHighNone
What do you do for a living?*
Your Skin
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)
What are your skin concerns?*
Do you have any known skin conditions? (Ex: dermatitis, vitiligo)*
CleanserSoapExfoliant (physical or chemical)MaskSerumsTonerMoisturizerEye CreamSPFVitamin A (retinol)
What skincare brand?
YesNo
YesNo
Waxing/sugaringThreadingLaser/ElectrolysisNone
AccutaneTretinoinRetin-APrescribed topical creamNone
Please specify which product or type, if you answered YES to the question above.
AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsNone
YES, within the last monthYES, within the last 2-3 monthsNO
Wear contact lensesHave a pacemakerHave metal implants (including permanent retainers)SmokeConsume AlcoholConsume CaffeineWear a face mask routinelyFrequent tanning beds
How often are you outside or in the sun?*
Females Clients
YesNo
YesNo
I acknowledge that I should follow proper aftercare instructions from any services provided at The Babe Cave Beauty Bar.

It is client's responsibility to notify the service provider of any updates to answers provided on this form. It is essential to notify your service provider of any new medications, skin treatments provided outside of The Babe Cave Beauty Bar, and any new allergies.

Please do not exfoliate or use active ingredients including serums and toners for 36 hours before AND prior to your service at The Babe Cave Beauty Bar.
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 (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

I release The Babe Cave Beauty Bar and its staff 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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Facial Treatment Consent Form

Your Medical History

Your Skin

Females Clients