Facial Intake/Consent Form

Name

First NameLast Name

Date of Birth

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you had a facial before?

Are you using any other skin thinning products and/or medication that thin blood?

If yes. please list.

Please list any other illness/conditions you are currently being treated for by a medical professional.

Are you currently (or have you ever) used Retin-A, Renova, or Accutane?

Have you had a chemical peel, laser, or microdermabrasion treatment in the last month?

What products do you normally use on your skin?

What areas of concern do you have regarding your skin; Please check all that apply

Do you have any special skin concerns? if yes, please describe below.

Do you have any allergies?

If yes. please list.

Have you ever experienced claustrophobia?

Are you pregnant or currently trying to become pregnant?

Do you consent to photos/videos to be taken of your treatment and/or treated areas to be used for documentation and/or advertising?

I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the treatments we discussed and will hold her harmless from any liability that may result from this treatment. I understand that my facial treatment may include clinical-strength products, enzymes, extractions, high frequency, LED light therapy, oxygen therapy and other treatment modalities as necessary.

I have listed all my known medical conditions and physical limitations. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider for any services rendered. I agree to adhere to all safety post care and all home skin care protocols as recommended by my service provider.

Signature

EstheticallyMell