Aleese Aesthetics
PROFESSIONAL TREATMENT CONSENT FORM
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies? If yes, please list.
Medical History
Are you currently, or have you previously experienced any of the following:
Heart condition
Pacemaker
Headaches
Anemia
Low Blood Pressure
Cancer
Thyroid Condition
Kidney Problems
High Blood Pressure
Arthritus
Hemophilia
Asthma
Diabetes
Hypo/Hyper gylcemia
Hepatitis
Herpes Simplex
AIDS/HIV Positive
Autoimmune
Skin Disease
Rosacea
Eczema
Psoriasis
Lupus
Keloid Scarring
Varicose veins
Other
Women
Please complete the following.
Are you pregnant?
Do you have any hormone imbalance?
Skin Self-Analysis
Please explain what you are wanting to change about your skin.
Is your skin:
Oily or Acne Prone
Dry
Normal
Sensitive
What skin care products are you currently using?
Are you wearing a daily sunscreen/spf?
Have you ever treated or been treated for a skin condition? If yes, what condition?
How did you treat this condition:
Dermatologist
Aesthetician
Self Treated Drug Store
If there is anything you are wanting to add, fill out below.
Authorization
By submitting and signing this form, I acknowledge, and consent to the following:
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments.
I acknowledge that the esthetician holds the right to terminate the session at any time.
I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received.
I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.
I release the esthetician from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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