Facial Client Intake and Consent Form

Facial Client Intake and Consent Form

Purely Alyssa Esthetics
Full Name

First NameLast Name
Date

MonthDayYear
Date
What is your age?

MonthDayYear
Date
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
When's the last time you had a facial?
Have you ever reacted to a facial service? If yes, please describe:
What is your skin type? (Dry, Oily, Sensitive, Acne Prone)
Are you or are you trying to become pregnant?
What facial are you receiving today?
Check the conditions that apply to you:

Other
Are you currently using any of the following? Please list any that apply: Accutane, Glycolic Acid, Retin A, Birth Control? Or say NA if none apply to you.
Are you currently taking any medications? If so, please list:
Are you allergic to any medications?
What are your skin concerns?
Is this for anything special? (Bridal, birthday, self-care, etc...)
I do/ do not grant permission Purely Alyssa Esthetics to use photographs and videos taken of me on the specified date in the specified location for marketing and publicity purposes. I understand photographs and videos may be used digitally, such as on social media or the website, brochures, for marketing and publicity purposes!
This signature consents that you understand and confirm that I have elected by my own decision to have a facial done. I have read the above information and have given accurate answers to the questions. I give the Esthetician permission to perform the facial procedure. I understand that there are often inherent risks associated with skincare services and I agree that as a condition for providing these services, I hold this studio, Purely Alyssa Esthetics, and the esthetician harmless from any problem that may result from this treatment.
Please sign below
Signature
Should be Empty: