• Treatment Consent Form

    NEW CLIENT

  • Your Information

    Clients under 18, must have Adult consent
  • Today's Date
     - -
  • Date of Birth
     - -
  • Format: (000) 000-0000.

  • Medical History

  • Have you experienced any of these conditions? Please check any/ all that apply.

  • Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for
    how long you used them.

  • Rows
  • Please check any you may be allergic too:
  • (WOMEN) Are you pregnant, breast feeding, on Birth Control or currently trying to conceive?

  • Please list the following Information for your Primary Care Physician

  • Lifestyle Considerations

  • Select the stress level that applies to you.
  • How often do you exercise?
  • Please select any that you per take in on a regular basis.
  • Estimated daily water intake (Oz)

  • Skin

  • When you wake up, how does your skin feel?
  • When you cleanse, how does your skin feel?
  • Please list your current number of acne lesions/ blemishes (per each side of face)
  • Select all that apply to your current Skincare Routine
  • Have you used or received these treatments/ products? Select all that apply.
  • What was the outcome of any of these treatments?
  • Are you or have you been, under the care of a Dermatologist?

  • Consent

  • How'd you hear about us?
  • I am ready and willing to dedicate myself to treatment plans and product recommendations.
  • I understand results may, and can take up to 3-4 months to be seen.
  • I consent to BEFORE/ AFTER photos in order to track personal progress, and/or Social Media

  • I have read and understood this Form in it's entirity. Any questions or concerns I may have, have already been addressed with my Esthetician. I understand that receiving a treatment means following correct Home Care instructions/ products. Redness, inflammation, dryness, and purging may occur. I consent to following specific Post- care instructions. Including but not limited to: SPF, no sun for up to a week, no actives or exfoliants up to a week, no new products without consulting Esthetician. I agree to all effects that come with a treatment. I consent to receiving Treatment.

  • Should be Empty: