Facial | Waiver & Consent Form

This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only to 1)Our Staff & 2) Our product supplier and manufacturer (if the result of a reaction). We will not provide the information to anyone else, except as required by law, and we will not sell this information to anyone.

Name

First NameLast Name

Parent’s name (if client is a minor)

First NameLast Name

Phone Number

Date of Birth

MM/DD/YYYY

1. Within the last year, have you been under a dermatologist’s or other physician’s care?

If yes, please specify

2. Have you has 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 have any allergies? Latex, nickel, etc.

If yes, please specify

5. Have you ever had an allergic reaction to aspirin?

6. Have you ever experienced claustrophobia?

7. What are your specific concerns or challenges with your skin?

8. Have you had a chemical peel, microdermabrasion, laser or light therapy, and injectable or other cosmetic procedure in the last month?

9. Have you waxed in the last 3 days?

10. Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?

11. Have you taken isotretinoin (Accutane) within the last 6-12 months?

12. Are you currently using any products that contain the following ingredients? Select all that apply.

13. Do you ever experience these conditions?

14. Do you use SPF on your skin?

15. Do you burn easily in moderate sunlight?

16. Have you had any direct sun exposure within the last 48 hours?

17. Do you have a tendency to redness?

18. Do you suffer from sinus problems?

19. Do you ever experience burning, itching, or stinging sensations on your skin?

If yes, please specify

20. What skin care products are you currently using? Select all that apply.

21. Are you pregnant?

22. Are you lactating?

I hereby acknowledge all risks associated with performing this procedure and have been informed of possible post-procedure side effects. Any concerns I have with this procedure have been addressed by my service provider. I understand that my service provider will take all necessary precautions to prevent risks from occurring during the procedure & release them from all liability when assuming these risks. I will adhere to all post-procedure recommendations made my service provider to ensure best quality of service.I certify that all above information is correct and that I have disclosed all conditions that may affect my quality of service and risks associated with my service provider. I have not withheld any information that may increase risks associated with agreed services.

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 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.

Add any additional notes here:

Signature

Facial | Waiver & Consent Form

Your Health

Your Skin