Sign Form

Sign Form
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemalePrefer not to say
Occupation
Have you ever received a brow lamination or a facial?

I’ve received both.I’ve only received a facial.I’ve only received a brow lamination.
If yes to either services, when was the last time you received a brow lamination or facial? Please state the service in your answer.
Are you on any form of Retinol/Vitamin A? (Tretinoin, Retinoic Acid, etc.) If so, please list them below.
If you are on any form of retinol/vitamin A (Tretinoin, Retinoic Acid, etc.) please stop at LEAST 1 week before your service.

I will stop as required.
Are you pregnant, planning to be, or are breastfeeding?

No to all of the above.I am pregnant.I am planning/trying.
Do you have any of the following medical conditions?

Epilepsy/seizuresHepatitis A/B/CRosaceaBruise easilyAutoimmune disorderMenopauseVaricose veinsClaustrophobicProne to redness/blush easilyMetal implantsPacemakerAnxietyEczemaPsoriasisCancerBlood clotsPCOSHormonal imbalancesThyroid disorderCirculation disorderMigrainesDiabetesNONE OF THE ABOVEOther
Please list any food, medication, ingredient, allergies that you know of.
Are you on Accutane or any other acne medication? If so, please list the name of the medication below. (If not, say no.)
Have you had any injectables (Filler, Botox, etc.) in the past 2 weeks?

YesNo
Have you had any recent surgeries, if so what was it?
Are you taking any medications (oral or topical) related to cosmetics or beauty improvements?
PHOTO/VIDEO RELEASE: I give Ashley Cocis Aesthetics permission to take photos and videos during certain treatments for Instagram/Website portfolio (when requested by Ashley in person). I understand I will not receive any financial compensation for photos or videos that may be taken.*

Yes, I give full permission and understand the conditions.No, I do not consent for any photos or videos to be taken.
I understand that I can be exposed to chemicals that are used for cosmetic benefits. (Such as chemical peels).*

Yes, I understand.
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happen, the clinic will not be liable. I fully read and understand the cancellation/rescheduling policy. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.*

I understand Ashley Cocis Aesthetics LLC. terms and conditions.
Would you like this to be more of a relaxing service or a talkative treatment?

Relaxing.Talkative.
BROW PREP:

Please stop all forms of retinol one week before your appointment. Do not come with any brow product on.

Try to grow out your brows as much as possible. Please do not trim your brows before the appointment.
FACIAL PREP:

No facial waxing 3 days before your facial. No laser hair removal 7 days before your facial. No Microdermabrasion 2 weeks before your facial. No botox, fillers or any injectables 2 weeks before your facial. No chemical peel 30 days before your facial.

Please try to come with a bare face if possible.
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