Bloom A Skincare Studio Consent Form

Name   First Name*   Last Name*
Date of Birth   Date*
Phone Number   Area Code*   Phone Number*
Email   Email*
Emergency Contact Name  First Name*   Last Name*
Emergency Contact Phone   Area Code*   Phone Number*

Healthy History - Please check any that apply:*

Allergies (list below)Skin Conditions (list below)Cold Sores or Herpes SimplexPregnant or NursingRecent use of Accutane (within the last 6 months)Current use of Retinol, Tretinoin, or other prescription creams (topical or oral)Current use of Vitamin C with HydroquinoneRecent Cosmetic Procedures (e.g., Botox, fillers, lasers) (list below)

List out anything from the above.

Services to be Received - Please check all that apply:

Acknowledgment of Risks - I understand and acknowledge following. Please check each one.*

Treatments may result in redness, flaking, breakouts, sensitivity, or irritation.Post-treatment care is essential and includes avoiding heat, sun exposure, harsh skincare products, and wearing SPF daily.Certain medications, health conditions, and active ingredients like retinol/tretinoin or hydroquinone may increase skin sensitivity and risk of adverse reactions.For waxing: skin lifting may occur if the skin is sensitive, thin, or if retinol or other exfoliants have been used recently.I must inform my provider of any new products or medications prior to future appointments.

Tretinoin / Retinol / Hydroquinone Consent

I understand that using active ingredients such as Tretinoin, Retinol, and/or Vitamin C with Hydroquinone can significantly increase skin sensitivity, especially during treatments involving exfoliation or waxing. I acknowledge that failure to discontinue these products at least 5–7 days before treatment may increase the risk of irritation, skin lifting, or adverse reaction.

I consent to proceed with treatment and acknowledge the risks associated with the use of Tretinoin/Retinol and Vitamin C with Hydroquinone.

Aftercare Responsibility

I have been informed of the appropriate post-treatment care and understand that it is my responsibility to follow these guidelines. I understand that not doing so may increase the chance of side effects or reduce the effectiveness of my treatment.

Waiver & Release

I confirm that all the information provided is true and complete. I understand the nature of the treatments I am receiving, the risks involved, and I consent to proceed. I release Bloom A Skincare Studio and its staff from any liability or claims related to the services provided.

Photo Consent (Optional):

I consent to before/after photos for documentation and marketing purposes.I do not consent to photos.

Signature