Newbie Consult Form

Today's Date*

Date

Full Name*

Date of Birth

Phone Number*

Address:

Email*

Occupation*

Emergency Contact *

Contact NameContact Number

How did you hear about Your Breast Friend?*

SocialsOnline SearchDirectly by YBFReferral

If referred, please name your source!

Are you currently under the care of a physician or skin care therapist?*

YesNo

Any recent surgery? (including plastic surgery)*

YesNo

Tick those that are applicable to you:

Additional info regarding the above:

In general, how are you feeling today? Think stress level, mood, aches/pains, current symptoms of above etc.

Please list any allergies or sensitivities:

Some products contain fructose, please note if you have an intolerance

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*

Do you suffer from sinus problems?*

YesNo

Do you ever experience claustrophobia? If yes, please let me know in more detail*

YesNo

What is your current stress level

What would you say is your main cause/s of stress at the moment?

Are you pregnant or breastfeeding?

YesNo

How are your breasts feeling at the moment?

Have you had a facial treatment before?

YesNo

Have you had a breast treatment before?

YesNo

Do you consent to having a breast treatment?

YesNo

If yes, when was your last facial or breast treatment?

What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure

Tick any that you currently using:

Acne MedicationPrescribed topical creamRetinol/Vitamin A derivative productsProducts containing Hydroquinone or Alpha HydroxyAHA's (Glycolic Acid, Lactic Acid, etc.)BHA (salicylic acid)

Tick if you have had any of these treatments recently

If yes to the above, roughly when was it?

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 monthsYES, longer than 3 months ago

Have you ever had an adverse reaction after using a skin care product?*

YesNo

If yes, what happened?

If yes, which products or brands?

Select all products you currently use on your skin?*

What is your daily skin care regimen?*

Do you use sunscreen?*

AlwaysOftenSometimesNever

What are your specific concerns regarding your skin?*

What is your skin care goal?*

What music do you relax to the most? If you have a preferred playlist/artist/song, please list below and that's what we will listen to. *

If you don't have a preference, no worries, I'll sort you out..

By submitting and signing this form, I confirm that I understand and agree to the following:

- I give permission to receive facials, skin treatments and/or breast treatments
- I understand that my esthetician is not a medical professional and does not diagnose conditions, treat illnesses, or prescribe medication.
- I confirm that I have received medical clearance to undergo these treatments, if necessary.
- I understand that while all products are chosen with care, individual reactions may occur due to allergies or skin sensitivities.
- I may experience temporary redness, tightness, swelling, or irritation, which typically resolves within 72 hours.
- I accept the risk of allergic reactions if I am sensitive to any product ingredients.
- I understand that not using sunscreen may increase the risk of sunburn, skin damage, or hyperpigmentation, and I should avoid excessive sun exposure directly after treatment
- I acknowledge that this is an elective, non-medical cosmetic treatment and no medical claims are being made.
- I agree to inform my esthetician of all relevant medical conditions, medications, and any changes to my health.
- I understand that my physical condition may involve additional risks and that I should communicate any discomfort during the session.
- Either I or the esthetician may end the session at any time.
- I have had the opportunity to ask questions and all my concerns have been addressed.
- I confirm that the information I have provided is accurate and complete.
- I give consent for all future treatments.

Use of Handmade Skincare Products
As part of this treatment, Your Breast Friend may use handmade, small-batch products made with natural and cosmetic-grade ingredients.
These products are:
- Prepared in a clean, hygienic environment
- Not for retail or commercial sale
- Used only during treatment
- Free from known harsh chemicals and preservatives

I understand these products are not commercially tested. I have disclosed all known allergies and sensitivities and accept responsibility for any reactions that may occur. I understand this treatment is not a substitute for medical care and release Your Breast Friend from liability for any reaction or injury resulting from the treatment.

Signature*

Your Breast Friend

Medical History

Female Clients:

Your Skin

Customise your Treatment:

Your Breast Friend Client Consent & Acknowledgment Form