Client Facial Form

Client Facial Form

Disclosure, Consent Liability & Release
*Signature + Completed Form is Required for Service*
Please fill out & sign all forms prior to or before the time of your appointment.
Name*

FirstLast
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
(for birthday goodies)
How did you hear about us?*

ReferralYelpTikTokGoogleInstagramEveryWhereIsQueerOther
If referred, who referred you?
Referrals both receive $10 off services.
Medical History
Are you currently pregnant or nursing?*

YesNo
If yes, how many weeks?
Are you currently taking birth control?*

YesNo
Are you presently under a physician's care for any skin condition or other problem?*

YesNo
Have you been diagnosed with skin cancer?*

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

NoneAnemiaAny Active InfectionsAsthmaArthiritisBlood clotting disordersCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackHerpesHepatitisHIV/AIDSRheumatic FeverHigh Blood PressureKidney DiseaseLiver DiseaseSleep ApneaSkin CancerThyroid ProblemsNeurological DisordersSkin Disease/Lesions
Other illnesses not listed:
Do you have any known allergies or previous allergic reactions to any of the following?*

NoneAlgaeAnimalsAspirinCosmeticsDairyEssential OilsFoodLatexMedicineNiacinNutsSalicylic AcidShellfishSulfurSunscreenOther
If yes, please list any allergies.
Please list any surgeries, including plastic:
Have you had Botox or Dermal Fillers?*

YesNo
Are you currently taking any medications?*

YesNo
Please list any current Oral and Topical Medications:
Facial History
Is this your first facial treatment?*

YesNo
Do you have acne?*

YesNo
Are you or have you used Accutane within the past 6 months?*

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

YesNo
What areas of concern do you have regarding your skin?*

Blackheads/WhiteheadsBreakouts/AcneBroken CapillariesCongestionDeep WrinklesFine linesDiscolorationDull/DrynessOily SkinOther
Do you have sensitive skin?*

YesNo
Which of these products are you currently using on your face?*

SoapCleanserTonerScrubMaskCreamMoisturizerSuncreenOtherNone
Have you ever experienced any of the following conditions with your skin? (Check all that apply)*

FlakinessTightnessDrynessSensitiveScarsOtherNone
Do you smoke?*

YesNo
How much plain water do you drink daily?*

NoneMinimalModerateFrequent
Consent & Release
I understand:*

The goal of a Facial treatment as in any cosmetic procedure is improvement, not perfection. I understand that my results may not be perfect. In the case of a facial treatment, the number of treatments necessary and result experienced will vary among individuals and the areas being treated.The practice of cosmetology and aesthetics is not an exact science and that no specific guarantees can or have been made concerning the expected results.My facial treatment may include clinical-strength products, enzymes, acidic peels, dermabrasion, dermaplaning, extractions, microcurrent, electrical muscle stimulation, galvanic, high frequency, ultrasonic, LED light therapy, oxygen therapy and other treatment modalities a necessary.Experiencing some redness or mild sensitivity such as stinging, hotness or tightness senation of the skin is normal.Despite the use of the most advanced and high-quality products and ORGANIC ingredients, an allergic reaction is possible. I agree that if I experience any medical conditions with my skin, I will contact my technician and if necessary, consult a physician at my own expense.My specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult her immediately.Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform my specialist of any changes in my medical history, current medications and/or changes relevant to this procedure prior to any future treatments.It is my responsibility to advise the specialist of any concerns I may have before these procedures.
Aftercare
By signing below, I agree to follow all aftercare instructions given to me by my specialist to ensure proper and sufficient healing process to achieve the best results.

I understand that if I have any concerns, I will address them with my specialist. I give permission to my specialist, Sophia Luong, to perform the said procedures we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment.

Photography
By signing below, I consent to photos being taken before and after treatments for client notes and documentation that may be used on social media however, client privacy is important to us and any photo used will be cropped appropriately if required.

LIABILITY RELEASE AGREEMENT

I understand that if I have any concerns, I will address them with my specialist. I give permission to my specialist, Sophia Luong, to perform the procedures we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment.

I understand my specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult her immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I do not hold the specialist or SOLUXBeauty LLC., responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.
I have read and agree to all the terms above.*

I agree.
Today's Date*

MonthDayYear
Signing Date
Signature *

Clear
By signing, you agree to all terms and conditions.
Thank you for submitting, service you soon!

SOLUXBeauty | Sophia L. ♡
Should be Empty:

Client Facial Form

Medical History

Facial History

Consent & Release

Thank you for submitting, service you soon!