New Client Facial Consultation & Consent Form

New Client Facial Consultation & Consent Form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Your Medical History
YESNO
Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
YESNO
LowMediumHighNone
Your Skin
What are your skin concerns?
Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
YESNO
YESNO
Waxing/sugaringThreadingLaser/Electrolysis
AccutaneRetin-APrescribed topical cream
Please specify which product or type, if you answered YES to the question above.
How many cups of water are you consuming per day?
AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
YES, within the last monthYES, within the last 2-3 monthsNO
Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
YESNO
YESNO
I acknowledge that the treatment I am receiving is an elective cosmetic procedure, with no medical claims expressed or implied. I understand that I may experience temporary skin irritation, tightness, redness, or slight swelling, which typically subsides within 72 hours depending on my skin's sensitivity.

I recognize the importance of using a minimum SPF 30 sunscreen post-treatment to reduce the risk of sunburn, skin damage, and hyperpigmentation. I will avoid excessive sun exposure, particularly between 10 a.m. and 2 p.m. following the procedure.

I acknowledge the potential for allergic reactions if I am sensitive to any ingredients in the products used. I will also avoid using Retin-A products, aggressive exfoliation, waxing, or any acidic products that are not part of the recommended post-treatment regimen provided by my esthetician.

To the best of my knowledge, I confirm that the information I have provided is accurate and that I have not withheld any relevant details about my health or skin condition. I consent to this treatment and all future treatments.

Finally, I release Blooming Daisy Esthetics from any claims, expenses, damages, or liabilities and agree to hold them harmless.
We at Blooming Daisy Esthetics would be honored to share your skin progress and treatment experience with our community. With your permission, we would like to use photos or short video clips taken during your treatment for marketing and advertising purposes, including portfolios, online and print advertisements, and social media platforms like Instagram (@bloomingdaisyesthetics).Your consent is required for us to use your photos/videos. Please indicate your preference below by signing the appropriate section to either grant or withhold permission for the use of your images for advertising.I hereby consent to the use of my photos/videos for advertising purposes.

Sure, I would love to!No, I'm shy.
Signature
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New Client Facial Consultation & Consent Form

Your Medical History

Your Skin