Facial Client Consent and Health Information

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date

List all medications currently taking:

List all known allergies:

are you allergic to aspirin?

What do you want to improve about your skin?

Are you currently taking any skin sensitizing, retinoid, or topical prescription creams like Tretinoin? Retin-A ,Accutane ,or Differin? If so, how often do you use it? When was the last time it was used?

Are you pregnant or breast feeding?

Do you use any Alpha-Hydroxy-Acids or Beta-Hydroxy-Acids (AHA/BHA) products at home? Please list the products, how often you use it, and when the last time it was used.

I consent to photographs and/or video images to be used for research, clinical data or social media purposes. If accepted, staff members may take pictures before/after Facial treatments,Peels Dermaplane, brow waxing or threading, lash lifts or brow lamination. *

I give my permission to receive facials, peels, skin care treatments, eyebrow services, or waxing services. I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications. I have obtained clearance from my physician to receive facials, skin treatments, and waxing services. I understand the risks associated with facials and waxing, such as superficial bruising, tenderness, or redness. I acknowledge that my skin might experience temporary irritation, tightness, redness, or slight swelling, which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I understand that failing to use minimal sunscreen (SPF35) makes me more susceptible to sunburn, skin damage, and hyperpigmentation. I should avoid excessive sun exposure.

I acknowledge that this treatment is a strictly elective cosmetic procedure, and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, hydroquinone, bleaching products, aggressive exfoliation, extreme sun exposure, and other products containing acids that are not part of the recommended take-home regimen, pending skin sensitivity, for up to one week before and after any of the above-mentioned treatments.

I understand the importance of informing my esthetician about all medical conditions and medications I am taking, and notifying the esthetician of any changes to these. I understand that there may be additional risks based on my physical condition.

I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so that he/she may adjust accordingly. I understand that either I or the esthetician may terminate the session at any time.

I have had the opportunity to ask questions about the session, and my questions have been answered. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.

I give consent for all future treatments. Therefore, I release Velvet Esthetics LLC and its staff from all liability associated with any injuries and/or current and future conditions resulting from the skincare treatments, waxing procedures, or products.

Signature

Facial Client Consent and Health Information

Photo Consent