Facial Consent Form

Facial Consent & Skin Questionnaire

Please fill out completely
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Emergency Contact *

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
How did you hear about us?*

InstagramGoogleFacebookFamily/FriendWalk InOther
Have you had a facial before?*

YESNO
Have you ever had any issues with your previous facials?*

YESNO
What were the issues?*

Break outsReactionOther
How would you describe your skin?*

NormalCombination (ex. Oily Tzone but dryness on chin)DrySensitiveOilySun Damaged
What are your specific skincare concerns or like to improve?*

Dryness/ flaky skinFine Lines and wrinklesBlackheadsAcneLoss of FirmnessAcne ScarsClogged PoresSkin TextureEnlarged PoresHyperpigmentation/Uneven toneRednessSkin SensitivityRosaceaOily SkinSkin dullness/brighteningOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
What is the skincare brand you use?*

I don't use skincareOther
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsTopical AntibioticsAccutaneDifferinRetin-ATazaracRenovaHydroquinoneNo/NoneOther
When, and how long have you been taking these products?*
Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Have you received botox or fillers?*

YesNo
You selected "Yes" to Botox or fillers, please list what location on your face and when?
Medical History Questionnaire
Any known allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential oilsTree NutsDairySunscreenPollenGlutenEggSoybeanNoneOther
Please list medications and/or supplements you are currently taking:*
Medications / Supplements
Have you ever experienced claustrophobia?*

YESNO
Have you ever experiences vertigo or issues laying flat?*

YESNO
Have you experienced any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart disease/ ConditionsArthritis/BursitisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold sores/blistersHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesBruise easilyMetal ImplantsPacemakerSmoker/Former SmokerHepatitisNoneEczemaPhlebitisVaricose VeinsThrombosisHyperthyroidismHypothyroidismCataractsContact LensesHay FeverMenopausalNoneDental metal fillings/bridgeworkOther
You selected "YES" to Varicose veins. If Varicose veins are present on the face specifically, and tends to be severe, please indicate it here for the treatment plan to be adjusted:

YesNo
You selected "YES" for Phlebitis, please be advised due to pain, swelling and risk for blood clots any massage will be omitted to reduce risk. Please confirm that you are cleared by a physician to have this treatment:

Yes
You checked "YES" to Cataracts, please be advised due to pressure applied from massage or exfoliation during a facial, this treatment shouldn't be performed with any recent Cataract surgery. Please confirm that you are post surgery and/or cleared by a physician to have this treatment:

Yes
For WOMEN: Please select All that apply:

Taking birth controlPregnant or breast feedingTaking hormone replacementExperience hormone imbalancesNone of the aboveOther
For MEN: Please select All that apply:

Shave with an Electric ShaverShave with RazorExperience skin breakouts after shavingExperience Ingrown hairNone of the aboveOther
Informed Consent / Waiver Release Policies
Informed Consent / Waiver Release

I hereby agree to this treatment. I am aware that products used in facials, skincare treatments, and homecare may contain tree nuts, sulfur, dairy, fruit, and gluten. I acknowledge that the skin care professional with Array Esthetics & PMU may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of adverse reaction to a product used in facials. I will inform my skin care professional before treatment of severe allergies, as this may make me unable to receive the service.

I am aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications, and answered all questions honestly on the above form, and agree to update Array Esthetics & PMU as to any changes. I understand it is my responsibility to disclose all medical, medicinal, and skin history, as Array Esthetics & PMU will not be responsible for reactions caused by undisclosed medical history.

I understand that the services offered are not a substitute for medical care. I understand that my skin care professional with Array Esthetics & PMU will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and post care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home care routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional with Array Esthetics & PMU from any liability for adverse reactions that may result from this treatment.

Policies

1. If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is the policy of Array Esthetics & PMU to provide you with the best professional service and products customized for your skin goals.

2. 24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. By clicking the box, I’m acknowledging I have read, understand, and agree with the terms of these policies.

This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form. I understand that this agreement is binding and that I have read and fully understand all information listed above.
I consent to any relevant photographs/videos being taken before and after the procedure to document the results of the procedure to be used for internal purposes.*

Yes
[Optional/Requested] I consent to Array Esthetics & PMU to use "before & after" photos/ videos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at anytime withdraw such consent for specific photograph/videos by contacting the company, which will then discontinue use of said photo/video(s).*

YesNo
Date*

MonthDayYear
Date
Signature*

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Parent/ Guardian Signature if client is under 18years old

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Facial Consent & Skin Questionnaire

Medical History Questionnaire

Informed Consent / Waiver Release Policies