Client Consent Form
Client Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Esthetician's Name
First Name
Last Name
Please take a moment to answer the following questions
Are you presently taking any medications?
Yes
No
Please list
*
Are you pregnant?
Yes
No
Do you have any allergies to cosmetics, food or drug?
Yes
No
Please specify
What skin care products do you currently use?
Cleanser
Toner
Antioxidant Serum
Eye Cream
Spot Treatment
Moisturizer
Sunscreen
Vitamin C Serum
Face Oil
Chemical Peel
Other
Please specify
Have you had skin cancer?
Yes
No
Do you use acne medication?
Yes
No
Are you taking oral contraceptives?
Yes
No
Please check if you are affected by or have any of the following
Asthma
Cardiac Problems
Depression
Herpes
Fever Blisters
Anxiety
Epilepsy
Skin Disease
Hepatitis
High Blood
Pressure
Sinus Problems
Immune Disorders
Lupus
Eczema
Hysterectomy
I agree with
If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.
I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
Also I understand that;
The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future
Client Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
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