• Client Treatment Authorization Form

    This consultation form is used to evaluate your individual service needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.
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  • Would you like to receive news, promotions and special offers from Angela Branch Skin Care?*
  • What treatment are you having today?*

  • Within the last year, have you had any health problems that have affected or could affect your skin?*
  • Are you prone to keloid scarring, blisters, or cold sores?*
  • Do you have any other health condition(s) not mentioned previously?*
  • Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments?*
  • Do you wear contact lenses?*

  • If yes, we ask that you please remove before any facial service.

  • Do you have metal implants, a pacemaker or body piercings?*
  • Do you have any allergies, including foods, skin products or ingredients, animals, etc.?*
  • Do you have any sinus problems?*
  • Have you ever experienced claustrophobia?*
  • What skin care products are you currently using? Check all that apply.*
  • Have you had any chemical peels, microdermabrasion or any resurfacing treatments within the last 3 months?*
  • Have you had any waxing in the area(s) being treated within the last week?*
  • Have you used retinol, tretinoin, Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?*
  • Are you currently using any products that contain the following ingredients?*
  • Please specify if any of the following apply to you:*
  • Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?*
  • Do you have active cold sores?*
  • Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks?*
  • Do you sunbathe or use tanning beds?*
  • Have you experienced sensitivity or a reaction from any skincare products?*
  • Do you experience redness, itching, or stinging on your skin?*

  • Photo and Video Release

    I understand that my photos will be taken to obtain a baseline record of my skin and to monitor treatment effects, but will only be shared/released with my consent per the below:
  • I give my permission for Angela Branch Skin Care to release for marketing purposes any videos or photos of services performed on me and any information regarding these services that I have received including but not limited to its website, Instagram, Facebook, TikTok, print, visual and marketing materials under the following circumstances:.*

  • Client Consent

    I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. 

    The procedure contraindications, precautions and warnings have been explained to me including alternative methods, as have the advantages and disadvantages. 

    I am advised that though good results are expected, the possibility and nature of complications cannot be fully anticipated. 

    Therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the results of this treatment with Angela Branch Skin Care are not permanent as natural degradation will occur over time. 

    I have read this consent form and I understand the information contained in it. 

    I have had the opportunity to ask any questions about the treatment, including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. 

    I confirm that the information I have provided on this form is accurate, to the best of my knowledge, and that I have not withheld any information that will be relevant to my consultation. 

  • Today's Date*
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    2 digit month, 2 digit day, 4 digit year
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