Service Consent Form

Service Consent Form

Please complete this form at least 24 hours before appointment
Today's Date*

MonthDayYear
Date
Date of Birth *

MonthDayYear
Date
Client Name*

First NameLast Name
Phone Number*
Email*
example@example.com
How did you hear about Kylie Anne Esthetics?*

Facebook/InstagramOnline SearchReferralOther
If referred, by who?
Your Medical History
Are you currently under the care of a Physician / Dermatologist?*

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

Hormone ImbalanceCancerHigh Blood PressureDiabetesHeart ProblemsArthritisAuto-Immune DisorderAsthmaEpliepsy/SeizuresCold SoresHIV/AIDSLupusDepression/AnxietyHeadaches/MigranesNoneOther
Please explain here if you answered "Other" for the above question:
Please list any known allergies:*
List medications/supplements you are currently taking:*
This includes topical products like prescription Tretinoin.
Have you ever received botox or fillers? If so, where and when? *
Please note: it is recommended to wait a full 2 weeks (14 days) post-botox or filler to schedule a facial appointment
Your Skin
What are your top 2-3 skin concerns?*
What skincare products do you use on a daily or weekly basis?

CleanserTonerSerumFacial MaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinoid)
Do you experience routine breakouts or acne?*

YesNo
Have you ever been diagnosed with eczema, psoriasis, rosacea, or any other skin condition?*

YesNo
Have you received any of these facial hair removal services in the last 7 days?*

Waxing/SugaringThreadingLaser/ElectrolysisNone
Do you currently use:*

Accutane (or have used within the last 12 months)Retin-APrescribed topical creamNone
Please specify which product if you answered YES to the above question.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retonids)Exfoliating scrubsUnsureNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within the last monthYes, within the last 2-3 monthsNo
Do you:*

Wear contact lensesHave a pacemakerHave metal implantsSmokeFrequent tanning bedsNone
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or breast-feeding?

YesNo
Photo/Video Consent
I consent that Kylie Anne Esthetics LLC may take and use my photographs/videos/digital content on social media platforms (like Instagram, Facebook, website, etc.).*

YesNo
I acknowledge that cancellations must be completed at least 24 hours ahead of scheduled appointment time. Failure to do so will result in the card on file being charged 50% of the scheduled service cost.

I acknowledge that a no-show will result in the card on file being charged 100% of the scheduled service cost. I understand that if I am more than 10 minutes late to my appointment, the no-show policy will be applied.

I acknowledge that Kylie Anne Esthetics LLC requires a card on file at time of booking for the purpose of the above cancellation and no-show policy enforcement.
I acknowledge that my skin may experience temporary irritation, tightness, redness, peeling, and/or flaking, which usually dissipates within 72 hours depending on my skin and the treatment provided.

I acknowledge that if I have an active cold sore I cannot make an appointment until it has run its course (approximately 2 weeks). And if an active cold sore appears between the time I book my appointment and the appointment date, I will reschedule (with no fee) for a date at least 2 weeks later.

I acknowledge that it is recommended to discontinue use of exfoliants and retinoids 5-7 days before my scheduled appointment.

I acknowledge that Kylie Anne Esthetics LLC has the right to refuse any service that, in their professional opinion, should not be performed.

I acknowledge that I will receive aftercare recommendations/instructions post-treatment and if I do not follow those recommendations, I do not hold Kylie Anne Esthetics LLC liable.

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 Kylie Anne Esthetics LLC and its staff of any liability associated with any injuries and/or current and future conditions resulting from skincare procedures or products.
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Service Consent Form

Your Medical History

Your Skin

Female Clients

Photo/Video Consent