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Facial Form
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9
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1
Name
First Name
Last Name
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2
Date of Birth
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Date
Month
Day
Year
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3
What are your goals for your facial today?
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4
Have you ever had any chemical peels, laser resurfacing, microdermabrasion or laser hair removal? If so, when?
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5
Have you had any spa treatments done in the past two weeks? This includes waxing, botox, fillers etc.
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6
What does your at home skincare routine look like?
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7
Do you burn easily when exposed to sunlight?
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NO
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8
I understand that if I have any concerns, I will address these with my esthetician. I give permission to myesthetician to perform the above treatment/procedure we have discussed and will hold him/her/them andhis/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understandmy technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. Iagree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify thatI have read and fully understand the above paragraphs and that I have been provided sufficient opportunity fordiscussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold thetechnician/esthetician, whose signature appears below, responsible for any of my conditions that were present but notdisclosed at the time of this procedure that may be affected by the treatment performed today.
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9
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