Latin Image Skin Care Consulation Form

Skin Care Consultation Form
Date *

MonthDayYear
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Date of Birth (Under 18 must have parental consent)*

MonthDayYear
Date
Emergency Contact

Guardian of the client under 18 must complete the rest of the form
Guardian Information

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Services
What service are you having done? (You can select both for future treatments)*

Facial TreatmentsWaxing
Have you done any of the services above?*

YesNo
If yes, please explain date and service provided (including chemical peels, laser services, microdermabrasion, etc.) and any problems during any services:
What are you main reasons for a getting a Facial?*

Relaxation/ De-stress/ Self-careTo Target Skin ConcernsSkin maintenance/ Skin rejuvenationImprove skin healthOther
Your Skin History
What is your skin type?*

DryNormalOilyCombinationUnsure
For Facial Treatments: What are your main skin concerns? (Please check any of the following that apply to you):*

DrynessAcne/ Acne BreakoutsOilinessHyper/ Hypo PigmentationBlackHeads/ WhiteheadsDehydrationFine Lines & WrinklesEnlarged PoresSun DamageRough textureScarringDark Under-eye CirclesEye PuffinessFlaky SkinNoneOther
Have you used any skin-thinning, acne, or exfoliating product or treatments within the last 12 months (including but not limited to Retin-A, Renova, Adapalene, Accutane, Tazorac, Azelex, Differin, Glycolic acid, Salicylic, AHA treatments/product, Hydroquinine, Vitamin A, and so on)?*

YesNo
If Yes, please specify. Which ones? How regularly? PLEASE NOTE: If you take Accutane, must stop for a minimum for 1 year before getting a facial. *
Have you had any microdermabrasion, light therapy, laser resurfacing, injections or filler including but not limited to Botox, Collagen, Restylane, Dermal, etc. within the last 3 months?*

YesNo
If Yes, please specify. *
Do you use tanning beds, or have any excessive sun/ UV exposure (from work, vacation, location etc.)?*

YesNo
If Yes, please specify how frequent and last exposure. *
What Skin Care Products do you currently use?*

Cleanser / Face WashSunscreenTonerFace Scrub / ExfoliantsSerums, Concentrate, Facial OilFace MasksMoisturizerLip Product(s)Eye Product(s)
If you have checked any of the above, please provide details of the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions about ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Toner
Serum, Concentrate, Facial Oil
Moisturizer(s)
Eye Product(s)
Sunscreen
Face Scrub / Exfoliants
Face Masks
Lip Product(s)
What are your skin goals and/or expectations? *
Waxing
Have you received or done any of these hair removal services in the last week?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamRazor/ Wet ShaveNoneOther
Do you experience irritation, peeling, ingrown hairs, folliculitis, or pseudofolliculites(aka. razor bumps) from shaving?*

YesNo
Do you experience excessive hair growth (hirsutism or hypertrichosis)?*

YesNo
Your Health
Do you have any of the following skin conditions/ disorders? Please check any of the following that apply to you:*

RosaceaWartsPsoriasisSkin sensitivityLupusSkin CancerVitilgoEczemaDermatitisCouperose Skin/Spider veinsMelasmaNoneOther
Do you have any of the following health conditions? Please check any of the following that apply to you:*

Pregnant or Trying to beHIV/AIDSDiabetesTaking Birth ControlAutoimmune diseaseMenopause/Irregular PeriodsAny contagious diseaseFrequent StrokesEpilepsy / Seizure DisorderHeart/Liver/Kidney DiseaseFever Blisters/ Cold SoresCancer/ Chemotherapy/ RadiationEye Dryness/ Irritation/ InflammationAsthmaNursingFungual Infection/ConditionEasily Bleed/BruiseBlood/Circulatory DisordersEye Infection/DisorderHigh Blood PressureArthritisMetal Implants/ PacemakerNoneOther
If you checked any of the following skin or health conditions, please explain and specify. N/A if none applies.*
List all known allergies (N/A if none applies):*
List all medications you currently take (N/A if none applies) :*
Have you undergone any surgery or hormone therapy?*

YesNo
If yes, please specify history and last procedure:
Lifestyle
Do you smoke, consume alchohol or caffeine?*

Smoke (Vape, Cigars, Cigarette, etc.)AlchoholCaffeineNone/ Rarely
Do you take any Dietary or Vitamin supplements?*

YesNo
If yes, list all supplements to the best of your knowledge.*
Do you wear contact lenses?*

YesNo
Are you easily overstimulated?

YesNo
We want to create the most relaxing environment for you. Please let us know if you have a musical preference for your session.*

Suprise me!!Spa MusicClassical InstrumentalInstumental JazzModern Instrumental (Pop, uplifting)Modern Instrumental (Movie Themes)Energy Healing (Sound bowl, Frequency, Headpan)Nature Sounds (Rain, Ocean waves, Fire etc.)Silence, no musicOther
Any additional information or concerns you would like your esthetician to know:
Consent & Agreement
I hereby grant Latin Image Salon & Esthetician permission to use photographs or videos of me taken during my session on social media, websites, or advertisements.*

Yes, I consentYes, I consent. However would like to censor my faceNo, I do not consent.
I fully understand all the questions above and have answered them all correctly and honestly.

If I am under the age of 18, I understand that I must have a parental signature and consent. Parents must be present at all times during service. I understand that children under 16 are not served.

I understand that the services involve various techniques and products designed to promote skin health, beauty, & enhance relaxation. I acknowledge that services such as facial treatments involve massage on the face, shoulders, neck, and scalp.

I understand that the Esthetician, Jessica, is an Apprentice Esthetician and is considered a "student-in-training." The Esthetician will walk me through the procedure, including product, ingredients, benefits, effects, etc. And the Esthetician can change my booked appointment to fit my skin goals and needs. I understand the Esthetician may terminate the session at any time due to inappropriate remarks or behavior. And I understand that the Esthetician can refuse service due to any medical conditions that may be contagious or harmful to me, the environment, or the provider.

I understand the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, and pigmentation levels. And my lifestyle (smoking, outdoor exposure, tanning beds, excessive alcohol consumption, and/or recreational use of controlled substances) will affect and diminish the effectiveness and result of treatment.

I understand services are not a substitute for medical treatment or advice and are not a medical procedure to cure any diseases, illnesses, or injuries. I understand that the Esthetician does not diagnose or prescribe medications. I acknowledge that if I have any medical conditions, injuries, allergies, etc., that may be affected by the treatment and/or service, the Esthetician may not provide the service or require my physician’s clearance.

I acknowledge that there may be risks associated with the treatment/service. Depending on the service, I may experience, but not limited to, redness, soreness, swelling, sensitivity, allergic reactions, irritation, tingling sensations, etc. I understand it is my responsibility to inform the Esthetician of any discomfort during the session. And I understand every year, I will renew the consent form; however, any present or new information regarding medications, conditions, allergies, and more will be discussed immediately, and I must resubmit the consent form immediately.

I release Latin Image Salon and the Esthetician of any liability associated with any injuries and /or current and future conditions resulting from the skincare/waxing procedures or products. The company, Latin Image Salon, and the Esthetician are not responsible for any allergic reaction I may experience. And I have provided accurate information to the best of my knowledge.

I consent to the Esthetician services and future treatments/services. And I agree to follow the Esthetician's recommendations for aftercare to the best of my ability. I understand that aftercare is my responsibility and must follow the safety protocols given to me by the Esthetician for the best results and safety. Which includes but is not limited to: no hot tubs or saunas, no swimming, no sex or sweat-inducing activities such as gym, no tanning bed or exposure to UV/ sun, no chemical peels or skin-thinning, acne, or exfoliating products unless recommended by the Esthetician.
Client (or Guardian) Signature*

Clear
Should be Empty:

Skin Care Consultation Form

Emergency Contact

Services

Your Skin History

Waxing

Your Health

Lifestyle

Consent & Agreement