Spa Facial Consent

Client Name

First NameLast Name

Date of Birth

Email

example@example.com

Do you have any skin concerns today?

Please explain

Are you Pregnant or Nursing?

How many weeks?

Please list any allergies

Have you ever had any allergic reactions to any of the following? (Please check all that apply)

Have you had any of these health conditions in the past or present? (Please check all that apply)

Other illnesses:

Please list any Surgeries, including plastic surgery

Please list your Current Oral & Topical Medications

Are you or have you been on Accutane within the past 6 months?

Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5-7 days?

Have you had Botox or Dermal Fillers

If you have received any cosmetic injectables within 2 weeks of your appointment, please contact us to reschedule your appointment.

What areas of concern do you have regarding your skin?

If other, please explain:

Does your skin get red or irritated easily?

Do you wear Contact Lenses?

Are you Claustrophobic?

Alcohol Consumption

Do you smoke?

Do you vape?

Please list any skincare products that you are currently using and how often you use them:

Please read ALL of the following statements carefully and indicate your understanding and acceptance:

I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release Zoey Esthetics and any of its employees/staff against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.

By my electronic signature below, I give consent to receive treatments at Zoey Esthetics and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or Zoey Esthetics for any services rendered.

Signature

Date

Spa Facial Consent

General Information

Medical History