Facial Consent Form

Date*

Date

Name*

First NameLast Name

Date of Birth *

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral

If referred, by who?

If you have recently received Botox injections or lip filler treatments, or if you plan to do so, we kindly request that you refrain from scheduling your facial appointment within two weeks following these procedures. This waiting period allows for the Botox and lip fillers to settle properly, ensuring optimal results from both treatments.Performing facials too soon after Botox injections or lip filler treatments may inadvertently interfere with the settling process of these injectables and could potentially impact the outcomes of all treatments involved.*

Initial

🪩 Retinol Use Before Facials 🪩To avoid irritation and get the best results:Stop using retinol or retinoids at least 48 hours before your facial.Let me know if you use retinol regularly (including strength and how often) so I can adjust your treatment.Following these steps helps your skin respond beautifully!*

Initial

May I have your permission to take photographs of you during our sessions for promotional purposes? These photographs may be used on our website, social media platforms, and other promotional materials. Your privacy will be respected, and no personal information will be shared without your consent. Please indicate any preferences or restrictions you have regarding the use of your images.*

Are you currently under the care of a physician?*

YESNO

Have you experiences any of these health conditions in the past or present?

Any known allergies?*

List medications/supplements you are currently taking.

Have you ever received any botox or fillers? if so, where and when?

Products may be exchanged or returned within 10 days of purchase. Full refunds are issued for items in new condition and unopened. If the item has been opened, The Skin Bar Aesthetics offers 40% store credit as an alternative.

I agree to The Skin Bar Aesthetics 24 hour rescheduling policy. Any appointment canceled on the day of will incur a 30% charge of the total appointment cost. A no-show will result in a 50% charge of the total service.

Print name

Have you ever experiences claustrophobia?

YESNO

Please rate your stress level

LowMediumHighNone

What are your skin concerns?

What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)

What skin care products do you use on a daily basis?*

Do you experience any breakouts or acne?

YESNO

Have you been diagnosed with eczema, psoriasis or rosacea?

YESNO

Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis

Do you currently use:

AccutaneRetin-APrescribed topical cream

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO

Do you?

Are you taking birth control?

YESNO

Are you pregnant or breast-feeding?

YESNO

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release The Skin Bar Aesthetics of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Facial Consent Form

Your Medical History

Your Skin

Females Clients