• Intake & Medical History Form for a Facial 🌸

    Esthetician: Jasmine Marenco
  • Date of appointment *
     - -
  • Format: (000) 000-0000.
  • Have you had a facial before?*
  • Daily lifestyle*
  • Check the conditions that apply to you or any member of your immediate relatives:
  • Check the symptoms that you' re currently experiencing:
  • Are you currently taking any medication?*
  • Do you have any medication allergies?*
  • Do you have any allergies or products in general?*
  • Are you under the care of a physician for any reason?*
  • How often do you consume alcohol?*
  • Rows
  • Do you use products now?*

  • Consent!

  • I * hereby consent to and authorize Jasmine Marenco to perform the following procedure:*.

  • I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved, by Jasmine Marenco.   *      

  • Are you ok with being posted for content?

  • Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, I also 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 additional cost. 

    I understand how important it is to follow all instructions given to me for post treatment care and the event that I have additional questions or concerns regarding my treatment or suggested home product/post treatment care, I will consult JASMINE MARENCO IMMEDIATELY! 

    I have also to the best of my knowledge given an accurate account of my medical history including all known allergies or prescription drugs or products I am currently ingesting or using topically. 

    I have READ and FULLY understand this agreement, and all detailed information above, I understand the procedure and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement I do not hold the esthetician who's signature appears below responsible for any of my conditions that were present but not disclosed at the time of this skin procedure which may be effected by the treatment performed today.

  • client name (printed) : * .

  • Esthetician: Jasmine Marenco

  • Should be Empty: