Facial Consent Form

Facial Consent Form

* Must be completed a minimum of 24h prior to your Booked Appointment
YOUR PERSONAL INFORMATION
Date*

DayMonthYear
Date
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender (Please type)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Country code (+44 for UK)Full Phone Number
How did you hear about us? (Please type)*
YOUR MEDICAL HISTORY

Please give as much information as possible as this allows us to determine your suitability for treatment
Please select any relevant skin conditions listed below which apply to you?*

Active AcneAsthmaAutoimmune DiseaseBlood Clots/Blood DisorderCancer or History of CancerCold Sores/Fever BlistersDiabetesEczemaEpilepsy or SeizuresAllergy to NickelHeart DiseaseHigh Blood PressureLow Blood PressureHIV/Aids/HepatitisKeloid ScarringKidney DiseaseLiver ConditionPsoriasisRespiratory ConditionRosaceaPolycystic OvariesThyroid ConditionNONEOther
Please list any/all medicines you are taking (if applicable)
Are you currently taking any blood thinning medicine? If the answer is yes, please use the 'other box' to explain*

NoOther
Do you have any allergies? (If you have an allergy not listed, please write this in the 'other' box*

NONETopical or Local Anaesthetics (Lidocaine, Tetracaine, Dermacaine, Epinephrine)Vitamin EBenzyl AlcoholNutsLatex/RubberNickel/Stainless SteelOther
In your opinion, how would you describe your skin type and skin condition? (Tick all that apply)*

DryOilySensitiveNormal/BalancedCombinationDehydratedAcne/Blemish ProneSundamaged/PigmentedOther
Are you pregnant or trying to become pregnant?*

YesNo
Are you currently Breastfeeding?*

YesNo
YOUR SKIN HISTORY

Please give as much information as possible as this allows us to determine your suitability for treatment
Have you had/used any of the following in the last 3 months?*

Acne Medication (Accutane/Epiduo)Retin-A or any Vitamin A derivatives (Retinol, Glycolic Acid/AHAsSurgeries (including Plastic Surgery)NONE
Have you had any of the following in the past 2-4 weeks? (IF YES, PLEASE USE THE 'OTHER' BOX TO SPECIFY THE DATE THESE WERE ADMINISTERED)*

Injectables (Botox, Dermal Fillers, PolynucleotidesChemical PeelMicrodermabrasionMicroneedlingNONE
Are you under the care of a Dermatologist?*

Yes (I will use the 'other' box to specify what care I am receiving)NoOther
What kind of setting/environment do you prefer for your facials?*

Relaxing - Relaxing music, no talking, pure indulgence & 'me time'Friendly - Chatty, informal, radio music playing
What are the main concerns with your Skin that you'd like to address?*
I understand that Skinfluence Facials are not suitable if I am Pregnant or Breastfeeding*

I confirm I am not Pregnant or Breastfeeding
I understand that I must not have been actively sun exposed (i.e. on a sun exposed holiday) in the 7 days before my facial and that I should not be sun exposed in the 7 days after my facial). If this is to be the case I must reschedule my appointment (noting the 48h cancellation policy)*

I confirm & agree
I understand that I must not have used any Retinol or Glycolic Acid at least 3 days prior to any facial treatment*

I confirm I have not/will not use any Retinol or Glycolic Acid at least 3 days prior to any facial treatment
I understand that I must arrive to my Facial Appointment completely free of Make Up/Skincare Products and that there will be an additional £5 charge to remove any Make Up (including Tinted Moisturiser)*

I confirm that I understand that I must arrive free of Make Up/Skincare Products and that there will be an additonal £5 charge to remove Make Up (including Tinted Moisturiser)
Do you consent to before and after photos being taken to monitor the progress of your Skin Journey & results*

YesNo
Do you consent to photos/videos taken during the treatment being posted to social media (so long as your identity is protected and you are informed/asked at the beginning of each treatment and shown the images for approval?*

YesNo
INFORMED CONSENT

Please read the following very carefully
By signing the below, I acknowledge that I have provided complete & accurate information and understand that this will be used to assess my suitability for any treatment.

I understand that it is my responsibility to inform Skinfluence Surrey of any changes to my medical history or Skincare routine prior to the commencement of each and every treatment.

I agree to waive all liabilities of Sineal Cotsworth or Skinfluence Surrey for any inury or damages incurred due to misrepresentation given by myself of my health history.
Name

First NameLast Name
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Facial Consent Form

YOUR PERSONAL INFORMATION

YOUR MEDICAL HISTORY

YOUR SKIN HISTORY

INFORMED CONSENT