• Consent & Skin History Form (Confidential)

    Thank you for completing this before your appointment with Skin by Cynthia
  • Today's Date*
     - -
  • bIRTHDAY*
     - -
  •  -
  • Does your job require you to work outside?*
  • How did you hear about Skin by Cynthia?*

  •  -
  • What is your hereditary background (check all that apply)?*
  • Do you require any special accommodation?*

  • Medical History

  • Have you seen a Dermatologist in the past year?*
  • Are you currently under the care of a physician or skin care therapist?*
  • Any FACIAL OR BODY surgery, including plastic surgery?*
  • Are you currently taking any antibiotics or meds due to FACIAL OR BODY surgery?*
  • Do you have or have ever had any of the following?*

  • Any known allergies (check all that apply)?*
  • Do you (check all that apply)?*
  • Do you suffer from sinus problems?*
  • Have you ever experienced claustrophobia?*

  • Medical & Health History:

  • Are you pregnant or trying to become pregnant?*
  • Are you breastfeeding?*
  • Are you taking any oral contraceptives?*
  • Are you undergoing any hormone replacement therapy treatments?*

  • Your Skin

  • Have you had a facial treatment before?*
  • If yes, when was your last facial or skin treatment?
     - -
  • Have you ever had a body treatment before?*
  • Which of the following describes your skin best?*
  • Have you received any of these skin care treatments?*

  • If you checked any of the above, please select one:
  • Are you currently using any products that contain or are you taking any of the following?*
  • What do you consider your skin type?*
  • Do you have frequent breakouts?*
  • What skin care products do you currently use?*

  • Do you use sunscreen?*
  • What are your skin concerns at this time (check all that apply)?*
  • Area of concern: EYES*
  • Area of concern: lips*
  • Do you experience irritation from shaving?*
  • Do you experience any ingrown hairs as a result of hair removal?*
  • Have you recently used any self-tanning lotions, creams, or treatments including a tanning bed?*

  • Lifestyle

    Lifestyle & dietary choices will help me understand skin concerns
  • How many hours do you sleep at night?*
  • Do you wear contact lenses?*
  • How often do you travel on a plane?*
  • Do you smoke cigarettes, vape, or consume other tobacco products or smoke marijuana? some treatments require you to stop for 24hrs pre & post-treatMENT*
  • Indicate what services or areas for which you are interested in (check all that apply):*

  • Future Appointments & Contact

  • Can I call, text or email you regarding future appointments or updates re: your skin routine?*

  • By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent, and agree to the following:

    I give my permission to receive cosmetic facials and/or skin care treatments, including a Hydrafacial(s). 

    I understand that the esthetician does not diagnose illnesses or injuries or prescribe medications.

    I have clearance from my physician or other professionals treating me to receive facials, skin treatments, Hydrafacial(s), and/or facial lymphatic therapy.

    I understand the risks associated with facials and waxing include, but are not limited to:
    • Superficial bruising or redness
    • Short-term muscle soreness
    • Exacerbation of undiscovered injury

    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 (SPF 30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.

    I acknowledge that this treatment is strictly an 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 not part of the recommended take-home regimen following treatment. 

    I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risks based on my physical condition.

    I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly.

    I understand that I or the esthetician may terminate the session at any time.

    I have been given a chance to ask questions about the session and my questions have been answered. I have reviewed the Policies tab on the SBC website which can also be found here.

    I understand that if I reschedule or cancel with less than 72 hours in advance, I will be charged the full-service amount. A NO SHOW will result in a full service charge.

    I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

    I am at least 18 years of age OR if I am not 18 years of age my legal guardian is present and giving their full consent.

    I, therefore, release Cynthia Delgado, Skin by Cynthia, Napa Valley Collective and its staff of from all and any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.

  • Should be Empty: