Facial Waiver Form

Facial Waiver Form

Provided by Eyedentity Studio | 3242 NE 45th St, Seattle, WA 98105 | 206.567.7705
Name*

First NameLast Name
Pronouns
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Skin Treatment and Needs

Your answers to the following questions will help your esthetician create a treatment plan tailored to your goals and current treatment(s) you may be undergoing.
What are your long-term skin goals?
What are your areas of concern?
What are your goals for this treatment?
Is this your first facial?*

YesNo
If no, when was your last facial?
Are you pregnant?*

YesNo
Are you taking birth control?*

YesNo
If yes, what type?
Are you presently using (or used in the past) Azlex, Differin, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids?*

YesNo
If yes, when and for how long?
Are you using, or have you ever used Accutane?*

YesNo
Do you wear contact lenses?*

YesNo
Are you presently taking any medications we should know about?*

YesNo
If yes, please list:
Have you ever had skin cancer?*

YesNo
Do you often experience stress?*

YesNo
Do you smoke?*

YesNo
Please list any allergies:
What skin-care products do you use, presently?
Please check if you are affected by or have any of the following:

Asthma Cardiac ProblemsAnxietyHigh Blood PressureFever BlistersHeadachesHepatitisMetal bone, pins, or platesHyserectomySkin DiseaseHerpesSinus ProblemsImmune DisordersEpilepsyLupusDepressionEczemaOther
Please explain or list any other significant issues we should know about:
I have read the above information and have given an accurate account of the questions. If I have any concerns, I will address these with my esthetician before the service. I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature.

I give permission to my esthetician to perform the facial service and will not hold the esthetician Eyedentity Studio accountable for any liabilities that may result from this treatment. I understand that the information here-in is to aid the esthetician in giving better service and is completely confidential.
By typing my name in the box below, I agree to the terms of receiving skin and facial services from Eyedentity Studio. *
Full Name
Date*

MonthDayYear
Date
Treatment of Minor

For clients under the age of 18.
By typing my name below, I hereby authorize Eyedentity Studio to administer facial treatment services to my child or dependent as they see necessary.
Parent/Guardian Name
Date

MonthDayYear
Date
Should be Empty:

Facial Waiver Form

Skin Treatment and Needs

Treatment of Minor