The Beauty Studio Facial Consent Form

Facial Consent Form
You have the right to be informed about your treatment, so you may decide whether to undergo the treatment after knowing the risks and benefits involved. This disclosure is an effort to make you better informed so that you may consent or withhold consent for the treatment. Please sign below that you have read and filled out this facial consent form.
Name*

First NameLast Name
Signature*

Clear
Parent Name if under 18

First NameLast Name
Parents Signature, if under 18

Clear
Today's Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Referred By:
Email
example@example.com
Your Birthdate

MonthDayYear
Date
Have you ever had a facial?

YesNo
If yes, when?
Do you have any special problems or concerns pertaining to your skin or body?

YesNo
If yes, please specify.
Do you have any known allergies?

YesNo
If yes, please specify. (Scents, latex, oils, etc.)
Do you Retin-A, AHA, or Retinol derivative products?

YesNo
If yes, please specify.
Used in the last 3 months?

YesNo
If yes, when?
Have you ever had chemical peels, laser, or microdermabrasion?

YesNo
If yes, when?
Are you on any acne medication?

YesNo
If yes, when and which medication?
*I ask just to make sure there is no irritation to the skin during a treatment.
What skin products are you already using? Please list any cleansers, daily moisturizer, exfoliator/scrub, toner, SPF, masks, other. List brand if known.
What areas of concern do you have regarding your skin?

Breakouts/AcneBlackheads/WhiteheadsExcessive Oil/ShineOther
If other, please explain.
Should be Empty: