• Skincare Facial Consent Form

    New Clients
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • How did you hear about us?*

  • Your Medical History

  • Are you currently under the care of a physician or taking any Medication?
  • Have you experiences any of these health conditions in the past or present?*
  • Any known allergies?*

  • YOUR SKIN

  • What would you say your skin type is?*
  • What skin care products do you use on a daily basis?*
  • Do you experience routine breakouts or acne?*
  • Have you ever been diagnosed with eczema, psoriasis or rosacea?*
  • Have you received any of these facial hair removal services in the last 7 days?*
  • Do you currently use?
  • Are you currently using any products that contain*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?*
  • Do you?*
  • Are you taking birth control?*
  • Are you pregnant or breast-feeding?*

  • I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice  Failure to do so will result in the loss of a  Booking fees $25. I acknowledge that ANY no show will result in the loss of a booking fees. I understand that after 15 minutes of tardiness mappointment may be subject to cancellation and I will be responsible in accordance with the “No-show policy.

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    • 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 agree to Keep my esthetician informed about any changes in my medical history ensures to get the best possible care tailored to my needs. 
    • I acknowledge that if I am allergic to one or more ingredients in the products used or recommened by esthetician, 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.
    • "We prioritize your well-being above all else. Should you encounter any discomfort or unease at any point during your session, we encourage you to notify us promptly. Your feedback allows us to tailor our approach to ensure your comfort and satisfaction."
    • 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 Bloom Esthetics -Skincare and Laser(Sukhmeet Esthetics) and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

  • IMAGE & VIDEO CONSENT

  • Do you authorize Bloom Esthetics to take photos or videos of pre and post treatment.*

  • *Consent for Photography, Filming, and Other Media*

    • I, the undersigned, hereby grant permission to Bloom Esthetics Skincare and laser or Sukhmeet Esthetics, its representatives, employees, or agents, to take photographs, videos, and/or other media recordings of my treatment sessions, before and after the procedure(s), and during any part of my care.
    • I understand that the purpose of these photographs, videos, and other media recordings is for the following:
    •  Educational purposes for other patients and staff.
    • Promotional material in print, online, and social media.
    • Professional presentations or publications.
    • I acknowledge that my images or videos may be edited or altered and that my identity may be revealed through the use of my image or by virtue of the descriptive text or commentary.
    • I hereby waive any right to inspect or approve the finished photographs, videos, or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown.
    • I understand that I will not receive any financial compensation for any use of such photographs, videos, or recordings.
    • I also understand that I am free to revoke this consent at any time, upon which the use of new images or recordings will cease; however, any use prior to revocation will not be affected. I affirm that I am over the age of 18 years and have the right to contract in my own name. I have read the above authorization, release, and agreement, prior to its execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives, and assigns.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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