Essence SkinBar Facial Service Consent Form

Essence Skin Bar Facial Consultation Form

Hello! I'm so happy you're here and cannot wait to meet you! Please fill out the consultation forms before you book your appointment with me. For both your safety and mine, I need to make sure that all paperwork is properly taken care of. If consultation forms are not filled out, as stated on my website, I will not perform your service until everything is completed. Thank you in advance and I will see you in my treatment room real soon!
General Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Gender

MaleFemalePrefer not to say
Are you 18 years of age or over?*

YesNo
How did you hear about me?*

InstagramBare Beauty / OnlineTikTokReferralOther
If you were referred or selected other, please respond in detail:
Medical History
Are you currently under the care of a physician?*

YesNo
[Please select any or all that apply to you.]*

DiabetesProne to erythemaBruises easilyHepatitis A, B, C or DRosaceaEczemaPsoriasisCancerMetal ImplantsRecent Botox/Surgery/Face LifeClaustrophobiaEndomitriosisAnxietyBlood ClotsVaricose veinsPigmentation issues (Melasma, Hyperpigmentation, etc).Thyroid disordersSeizuresEpilepsyAlopeciaBlisters/Herpes SimplexBleeding DisordersChemotherapy/RadiationFainting EpisodesHIV PositiveKeloid ScarringMRSADermatitisShinglesAutoimmune DisorderSemaglutide/ Weightloss DrugLupusOther
Water Intake

0-8oz8-16oz16-32oz32-64oz+I don't drink waterOther
If other, please detail:
Have you every experienced claustrophobia?*

YesRarelyNo
Please rate your stress level.*

LowMediumHigh
Are you on Accutane or any oral acne medication?*

YesNo
If yes, please detail:
Are you on any blood thinning medications? If so, list them here. If none, please write "None".*
List any medications you take regularly: including vitamins, herbal supplements, aspirin, etc. If none, please write "None".
Do you have any known allergies?*

YesNo
If yes, please detail:
Are you on any specific diet or have any dietary restrictions?*

YesNo
If yes, please detail:
Have you had any fillers, Botox, or any injectables at all within the past 2 weeks?*

YesNo
Female Clients
Are you pregnant, breastfeeding, or planning to be?*

PregnantBreastfeedingPlanning to beNone of the Above
Are you on any form of Birth Control?*

PillIUDShotsNoneOther
Skin Routine + Concerns
Please select which skin products you use in your skin regime:*

Foam CleanserGel CleanserFacemaskMakeup removerExfoliatorMoisturizerFacial OilSunscreen (SPF)Serum(s)I do not have a skincare routineOther
If other, please detail:
What would you say your skin type is?*

Sensitive (reactive to fragrance, often red or irritated)Normal (No visible blemishes, smooth skin, fine pores)Dry (visible wrinkles, tight, flaky)Acnetic (cycts, papules, pustules, etc).Oily (enlarged pores, excess oil, "greasy" feeling)
What are your skin concerns?

Acne, breakoutsWhiteheads / BlackheadsDry skinOily skinDull skinDehydrated skinFine lines and wrinklesHyperpigmentation (dark spots)Sun damageAge spotsMelasmaScarsKeratosis pilarisIngrown hairsRazor burnRosaceaSkin erythemaPuffy eyesUneven skin toneUneven skin tecturePremature agingOther
Have you had a facial before?*

YesNo, First time!
If yes, when was the last time you received a facial and what type was it?
Have you every received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within a monthYes, within 2-3 monthsNo
What is your main skin concern and goals that you want to address or achieve through your skincare. service? *
Examples include: acne, acne scars, anti-aging/ fine lines & wrinkles, pigmentation disorders, dryness, oil control, redness, etc.
If you are on any form of a Retinol/Vitamin A, you must stop use Retinol/Vitamin A at least 72 hours before your scheduled facial.*

I am on Retinol/Vitamin A and understand/agree that I must stop use 72 hours before my facial as requiredI am not using any form of Retinol/Vitamin A
Is there anything else that you want me to know before providing you with your facial service to make it more comfortable or beneficial for you?
I understand that I can be exposed to chemicals that are used for beauty and cosmetic benefits, such as chemical peels.

Yes, I understand
Photo & Video Release:

I hereby give Essence SkinBar permission for any photos, videos, or audio that are taken of me to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications.This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.I renounce all claims I may have to royalties or other forms of payment resulting from or connected to the use of the image or sound recording.I understand and agree that these materials shall become the property of Essence SkinBar and will not he returned. By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement. In addition, I understand that I will not receive financial compensation for photos or videos that may be taken during this facial treatment.
Yes, I understand and agree.
Terms and Conditons

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that if I withhold some important information from Essence SkinBar and complications happen, the clinic will not be liable. I fully read and understand the cancellation, no-show and rescheduling policies. I release Essence SkinBar and hold harmless against any claims, expenses, damages, and liabilities. I understand that by booking and entering my card information, I am authorizing Essence SkinBar to charge my card fees associated with no-show and late cancellation policies. I understand that I can view cancellation policy details on Essence SkinBar's website.
Yes, I understand and agree.
Name*

First NameLast Name
Enter today's date:*

MonthDayYear
Date
Should be Empty:

Essence Skin Bar Facial Consultation Form

General Information

Medical History

Female Clients

Skin Routine + Concerns

Photo & Video Release:

Terms and Conditons