• Facials

    Consultation Form
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Facial Medical History

  • Have you experiences any of these health conditions in the past or present? Please select, if yes*
  • Have you ever had a Facial Before?*
  • Have you been diagnosed with eczema, psoriasis or rosacea?*
  • Do you currently use:*

  • Additional Questions

  • Your Skin Care Routine*
  • Have you experienced claustrophobia at any point?*
  • Please rate your stress level*
  • What would you say your skin current condition is?*
  • Do you experience routine breakouts or acne?*
  • Have you received any of these facial hair removal services in the last 7 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?*
  • Do you?*

  • Female Clients

  • Are you taking birth control?
  • Are you pregnant or breast-feeding?

  • Dermaplane Clients

    Please go to next page if you are not receiving Dermaplane treatment

  • I give my consent for Dermaplaning to be preformed by Zoe Broomfield,  

  • Dermaplaning is a physical exfoliation that removes dead skin cells and vellus hair from surface of the face, this form of exfoliation smooths the skin and allows for the active ingredients in skincare products and treatments to penetrate deeper which increases their efficacy & anti-aging benefits.

    Alternatives to dermaplaning include microdermabrasion and scrubs for exfoliation, and waxing, threading or cream depilatory for hair removal. There is no single treatment to replace dermaplaning.

    I understand there are contraindications to this treatment, including but not limited to diabetes, cancer, active acne, bleeding disorders and the inability for blood to coagulate following injury. Certain medications including blood thinners, higher dosage of Aspirin, and Accutane are contraindications for this treatment due to increased sensitivity and/or the possibility of delayed clotting from a nick or cut.

    I certify that I am not taking any of the above medications or experiencing any of the above conditions. Alternative treatment such as waxing to remove vellus hair and microdermabrasion for exfoliation, along with their associated risk, have been explained to me as other options.

    I understand this treatment involves the use of a specialized dermaplaning blade to remove dead skin cells and vellus hair. As with the use of any sharp instrument there is a possibility of injury. While every precaution is taken. I understand the risks and consent to receive treatment today.

  • Date
     - -

  • Chemical Peel Clients

    Please go to next page if you are not receiving Chemical Peel treatment

  • Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial: I understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).

  • I understand the above statement

  • I understand and agree to follow the home care instructions and recommendations provided by my esthetician: I understand that I will be responsible for following home regimens that can minimize or eliminate possible reactions including:

    • recognizing the importance of adhering to a sunscreen
    • avoiding the sun/tanning
    • avoiding extreme weather conditions
    • avoidng excessive exercise/heat (showers, suanas)
    • using skin care specifically recommended to me by my skin therapist.

  • I have read the above information. I have accurately answered the questions above, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my skin therapist to perform the chemical treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the skin therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.

  • Facial

    Consent Form

  • Although every precaution will be made to ensure your safety and well-being before, during and after your facial, please be aware of the possible risks below:

  • I have read the above information. If I have concerns, I will address them with my esthetician, Zoe Broomfield.

    I give permission to Zoe Broomfield to perform the facial procedure(s) we have discussed, and will hold her and AmourforBeauty, LLC harmless from any liability that may result from this treatment.

    I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically.

    I understand that my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

    In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately.

    I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

    I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.

    I understand the procedure and accept the risks.

    I do not hold the esthetician, Zoe Broomfield, responsible for any of my conditions that were present, but not disclosed at the time of the skin care procedure, which may be affected by the treatment performed today.

  • Date*
     - -
  • Should be Empty: