Facial Consent Form

Facial Consent Form

This form is not for waxing/sugaring clients. This form only needs to be filled out once a year or if you have a change in medical conditions.
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Email
example@example.com
How did you hear about us?

Facebook/InstagramGoogle/Online SearchReferral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?

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

Hormone ImbalanceCancer(other)/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisorderAsthmaEpilepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigrainesSkin Cancer
Any known allergies?

AspirinLatexFruitsShellfishLidocaineFragrance/essential oilsTree NutsDairySunscreenPollenOther
Explain Allergies and List Medications you are taking.
Have you ever received any Botox/Dysport/Xeomin and/or Fillers? If so, when was your last treatment?
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level.

LowMediumHighNone
Your Skin
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)Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
Do you use Over the Counter Skincare Brands like Cerave, Neutrogena, Dermalogica, or do you use Professional/Medical Grade Skincare brands like Glymed, Circadia , Skinbetter, ZO, Epionce.

OTCProfessional/Medical
Do you experience routine breakouts or acne?

YesNo
Have you ever 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
Do you currently use:

AccutaneRetin-APrescribed topical creamOther
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/retinoids)NiacinamideVitamin C
Have you ever received chemical peels, laser services, microdermabrasion/hydrodermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsYes, greater than 1 year agoNo
Do any of these apply to you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or breast-feeding?

YesNo
I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice and that Failure to do so will result in charging 50% of the total service cost to the card on file unless otherwise notified. Cards on file need to be kept current at all times, if a charge comes back with Insufficient funds then an invoice will be sent and payment is expected within 8 hours. Should you have a balance remaining after 8 hours, you will forfeit any future appointments until the balance is paid.

Select services will require a deposit for 50% of the service cost, this is due to the extra time required for set up to perform the service.

Deposits are non-refundable and will be deducted from your total service cost at the time of the apointment.

Refunds will not be given on Retail products or for services received
I acknowledge that no services or treatments shall be given that fall outside the scope of practice for the Oklahoma Esthetician License which includes deep tissue massage.
I understand that it is my responsibiity to inform the therapist of any changes in medical conditions, medications and skincare products that occur in ongoing appointments.

I understand it is my responsibility to inform the therapist of any discomfort experienced during the session so that the treatment can be adjusted as necessary.

Photos of your treatments may be taken to aid in record keeping, and to be used with your permission on social media to help advertise the services available. You may refuse posting of photos to social media but will need to inform the therapist.

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 fail to use a minimal sunscreen (SPF 30), 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 not part of the recommended take-home regimen for 2 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 Brenda Duncan of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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Facial Consent Form

Your Medical History

Your Skin

Female Clients