Flawless Facials

Date

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Area CodePhone Number

How did you hear about us?

If referred, by who?

Are you currently under the care of a physician? IF yes, please list why...

Other

Have you experiences any of these health conditions in the past or present?

For the Ladies...

Other

Any known allergies?

List medications/supplements you are currently taking.

*** Have you ever received any Botox, Dysport Face or Lip Fillers? *ATTENTION* YOU MUST WAIT TWO WEEKS after you receive ANY of those service(s) before you receive any kind of skincare service. Please list YES or NO. IF yes, please list the date your injectables were preformed on.

What are your skin concerns?

What skin care products do you use on a daily basis?

Do you experience routine breakouts or acne?

Have you been diagnosed with eczema, psoriasis or rosacea?

Have you received any of these facial hair removal services in the last 7 days?

Do you currently use:

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

Have you ever received chemical peels, laser services, microdermabrasion treatments or any treatments that were done by a dermatologist?

Do you?

Do you have any skin irregularities that are bothersome to you? Examples, skin tags, cherry angiomas, flat sunspots, seborrheic keratosis.

Other

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 acknowledge that if I fail to use a minimal sunscreen (SPF 30+), I am more susceptible to sunburn, skin damage & hyperpigmentation.

I acknowledge that this treatment is 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, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

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

I release Flawless Facials by Jo-Anne (Owner- Jo-Anne Monaco) of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Flawless Facials Skin Care Consent Form

Your Medical History

Tell us about your skin