The Beauty Studio 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

Parent Name if under 18

First NameLast Name

Parents Signature, if under 18

Today's Date

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Referred By:

Email

example@example.com

Your Birthdate

Date

Have you ever had a facial?

If yes, when?

Do you have any special problems or concerns pertaining to your skin or body?

If yes, please specify.

Do you have any known allergies?

If yes, please specify. (Scents, latex, oils, etc.)

Do you Retin-A, AHA, or Retinol derivative products?

If yes, please specify.

Used in the last 3 months?

If yes, when?

Have you ever had chemical peels, laser, or microdermabrasion?

If yes, when?

Are you on any acne medication?

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?

If other, please explain.