Esthetician Client Consent/Consultation Form
Please complete 24hrs before your appointment. Thank you!
Client Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Please enter valid Email (example@example.com)
Please take a moment to answer the following questions
How would you describe your skin?
*
Normal
Dry
Oily
Combo
Would you consider your skin to be sensitive?
*
Yes
No
What are your skin concerns? Choose any that apply.
*
Fine Lines / Wrinkles
Acne
Sun Damage or Melasma
Dehydration / Dullness
Texture
Dry / Flaky patches
Excessive oils
Redness / Irritation
Large Pores
Hyperpigmentation
Dark spots
Rosacea
Scarring
Other
Have you ever received a Chemical peel, Laser, Microdermabrasion, or any other abrasive treatment? If so please state when?
*
Are you presently taking any medications?
*
Yes
No
If Yes. Please Specify.
Are you pregnant?
*
Yes
No
Do you have any allergies or sensitivities to cosmetics, Essential oils, nuts, food or drug?
*
Yes
No
If Yes. 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
Retinols
I Don't Have a skin care regiment
Retinoids
Masks
Which products? Describe As much possible.
*
Do you use acne medication?
*
Yes
No
If Yes. Please specify
Are you taking oral contraceptives?
*
Yes
No
If Yes. Please specify
Do you have any Metal implants, Piercings or Pacemakers?
*
Yes
No
If Yes. Please state below which.
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
Cancer
Thyroid
Other
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.
I acknowledge that withholding relevant information or providing inaccurate misinformation may result in contradictions and or abverse results to the skin from treatments received.
The treatment I receive here are voluntary and I release this esthetician from liability and accept full resposibility.
Finally I confirm That I have
Read
,
Understood
and
Honestly
completed this Consent/Consultation Form.
Also I understand that;
The services offered are not substitute for medical care, and any information provided by the Esthetician is for educational purposes only and not diagnostically prescriptive in future.
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: