Facial Consent Form

Facial Consultation Form
This consultation form is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only to the service provider. We will not provide the information to anyone else, except as required by law, and we will not sell this information to anyone.

Questions with "*" are required . Other questions are not required but are preferred to get the best understanding of your skin & health for facial treatments & plans.
Name*

First NameLast Name
Phone Number*
Date of Birth*
MM/DD/YYYY
Emergency Contact Name *

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Your Health
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify
2. Have you had any health problems in the past or present?
If yes, please specify
3. List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
4. Do you smoke?
5. Do you exercise regularly?
6. Do you follow a strict diet?
7. Do you wear contact lenses?
8. Do you have metal implants, a pacemaker, metal braces, or body piercings?*
9. Your level of stress (1-5 being low, 5-10 being high)
10. Do you have any allergies? Latex, nickel, etc. *
If yes, please specify
11. Have you ever had an allergic reaction to aspirin?*
12. Do you sunbathe or use tanning beds?
13. Do you drink more than 4 caffeinated beverages daily?
14. Have you ever experienced claustrophobia?
Your Skin
15. What are your specific concerns or challenges with your skin?
16. Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?*
17. Have you waxed in the last 3 days?
18. Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?*
19. Have you taken isotretinoin (Accutane) within the last 6-12 months?*
20. Are you currently using any products that contain the following ingredients? Please pause using any of these ingredients / exfoliating products at LEAST 24 hrs or preferably 72hrs before your facial . Select all that apply.

Glycolic AcidLactic AcidExfoliating ScrubVitamin ABenzoyl PeroxideSalicylic AcidSulfur
21. What would you say is your skin type?
22. Do you use SPF on your skin?
23. Do you burn easily in moderate sunlight?
24. Are you usually in any direct sun exposure throughout your days?
25. Do you have a tendency to redness? *
26. Do you suffer from sinus problems?
27. Are you prone to cold sores or fever blisters?
28. Are you currently experiencing a breakout?*
29. Do you ever experience burning, itching, or stinging sensations on your skin?
If yes, please specify
30. What skin care products are you currently using? Select all that apply.

CleanserTonerMoisturizerExfoliatorSerumEye ProductSpf
31. Are you taking oral contraception?
32. Are you pregnant or trying?
33. Are you lactating?
34. Are you currently menstruating or due to?
35. What type of facial background noise would you like? I have a music playlist I play in the background as default…

Any music playlistClassical/Zen MusicMy own music playlistSilent appointmentPodcast
Are you sensitive to heat (facial steamer/warm towels)
I confirm that I am over/the age of 18. I confirm (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 confirm that treatments I agree upon are voluntary and the esthetician is not liable. I understand that same day cancellations result in 40% of my service charged. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms*

I agree to all terms & okay with pictures being taken and posted to social media.I agree to all terms & okay with pictures being taken for records but NOT posted to social media.I agree to all terms but NOT okay with pictures being taken or posted
Add any additional notes or questions here:
Signature
______________________
Should be Empty:

Facial Consultation Form

Your Health

Your Skin