FACIAL TREATMENT CONSENT FORM

Name*

DOB*

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Email*

example@example.com

Have you ever had a professional facial treatment before?*

YesNo

If yes when was your last facial treatment

Take a moment to answer the following questions about your health history. Your esthetician will discuss your health information in detail to decide what type of session best fits your unique health profile. Please be as honest as possible. Be assured this information is completely confidential.

Do you have high blood pressure and are you taking high blood pressure medication?*

YesNo

Do you suffer from epilepsy or seizures?*

YesNo

Do you frequently have stress?*

YesNo

Do you experience frequent headaches?*

YesNo

Are you pregnant?*

YesNo

Do you have any wounds or open lesions?*

YesNo

Do you bruise easily?*

YesNo

Do you have cardiac or circulatory problems?*

YesNo

Do you wear SPF protection?*

YesNo

Have you had any injections (Botox, Fillers) or a tan within the last 14 days?*

YesNo

Have you recently had PDO threads?*

YesNo

Do you have any skin conditions?*

YesNo

Do you have any contagious diseases? Such as herpes (cold sores), warts, impetigo, etc.*

YesNo

Are you currently taking any medications, vitamins, or supplements?*

YesNo

Do you consent to photos/videos during/before/after your facial/chemical peel services for purposes of educational material, marketing, promotions, etc? You can always opt out later. (By consenting you agree to no financial compensation in the present or future)*

YesNo

Do you have any aversions or sensitivities related to sense of smell? (Such as a distaste for lavender, candles, etc.)*

YesNo

Do you have any allergies or skin sensitivities? Please list*

If you answered yes to any of the questions above please describe

How did you find out about Lush Skin Studio?*

If there was anything about your skin you could change, what would that be?*

Please read and acknowledge. Inital each statement, this confirms you agree with each statement.

I agree that I am over the age of 18 am NOT under the influence of alcohol or drugs am NOT pregnant or nursing and capable of contracting in my name

I understand that it is impossible to list every potential risk and complication that could arise during or following my treatment however I have been informed of the general nature benefits risks and possible complications of the treatment or service I have voluntarily requested I recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost

I understand that my technician does not diagnose conditions nor do they prescribe or perform medical treatment prescribe substances or interfere with the treatment of a licensed medical professional I understand that a facial treatment does not take the place of medical care It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have

I have read and understand the post treatment home care instructions I understand how important it is to follow all instructions given to me for post treatment care If I may have additional questions or concerns regarding my treatment or suggested home product post treatment care I will consult the technician immediately

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment

6 I affirm that I have stated all of my known medical conditions and medications and answered all questions accurately and honestly I agree to keep the technician updated as to any changes in my medical profile and understand that there shall be no liability on the technicians part should I fail to do so

Date

7 I hereby consent to and authorize the business owner of Lush Skin Studio, Adriana Ramos to perform esthetic facial treatments along with extractions

I agree that I am over the age of 18 am NOT under the influence of alcohol or drugs am NOT pregnant or nursing and capable of contracting in my name*

YesNo

I understand that it is impossible to list every potential risk and complication that could arise during or following my treatment however I have been informed of the general nature benefits risks and possible complications of the treatment or service I have voluntarily requested I recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost*

Yes, I understand and agreeNo

I understand that my technician does not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional I understand that a facial treatment does not take the place of medical care It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have*

Yes, I understand and agreeNo

I have read and understand the post treatment home care instructions I understand how important it is to follow all instructions given to me for post treatment care If I may have additional questions or concerns regarding my treatment or suggested home product post treatment care I will consult the technician immediately*

Yes, I understand and agreeNo

I understand that any illicit, inappropriate remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment*

Yes, I understand and agreeNo

I hereby consent to and authorize the business owner of Lush Skin Studio, Adriana Ramos to perform esthetic facial treatments along with extractions and any optional add-ons I choose to add to our service*

Yes, I understand and agreeNo

I agree to Lush Skin Studio policies and guidelines as listed on the technicians website (lushskinstudio.me) I agree to a 50% cancellation fee in case of reschedule or cancellation less than 12 hours before our scheduled appointment. 100% of the service cost will be charged to the card on file for any no-call no-shows 12 hours or less before your schedule appt time. I agree to pay any dues due to not following Lush Skin Studio guidelines + policies, if I do not pay dues owed, you will not be allowed to book with the studio again until you pay off past due amount.*

Yes, I understand and agreeNo

I agree that I am over the age of 18 am NOT under the influence of alcohol or drugs am NOT pregnant or nursing and capable of contracting in my name*

Yes, I understand and agreeNo

I agree that I am over the age of 18 am NOT under the influence of alcohol or drugs am NOT pregnant or nursing and capable of contracting in my name*

Yes, I understand and agreeNo

I agree that I am over the age of 18 am NOT under the influence of alcohol or drugs am NOT pregnant or nursing and capable of contracting in my name*

Yes, I understand and agreeNo

I understand that it is impossible to list every potential risk and complication that could arise during or following my treatment however I have been informed of the general nature benefits risks and possible complications of the treatment or service I have voluntarily requested I recognize there are no guaranteed results and that independent results are dependent upon age skin condition and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost*

I understand that my technician does not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional I understand that a facial treatment does not take the place of medical care It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have*

I have read and understand the post treatment home care instructions I understand how important it is to follow all instructions given to me for post treatment care If I may have additional questions or concerns regarding my treatment or suggested home product post treatment care I will consult the technician immediately*

I understand that any illicit, inappropriate remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment*

I hereby consent to and authorize the business owner of Lush Skin Studio, Adriana Ramos to perform esthetic facial treatments along with extractions and any optional add-ons I choose to add to our service*

I agree to Lush Skin Studio policies and guidelines as listed on the technicians website (lushskinstudio.me) I agree to a 50% cancellation fee in case of reschedule or cancellation less than 12 hours before our scheduled appointment. 100% of the service cost will be charged to the card on file for any no-call no-shows 12 hours or less before your schedule appt time. I agree to pay any dues due to not following Lush Skin Studio guidelines + policies, if I do not pay dues owed, you will not be allowed to book with the studio again until you pay off past due amount.*

This agreement will remain in effect for the procedure and all future reoccurring

procedures of the same nature.

Is there a preferred name you be called by? Please add pronoun's as well.

Signature

Date

Print Name

Parent Guardian Signature If client under 18

Parent Guardian Print Name