Facial treatment Form

Name

First NameLast Name

Date

Date of birth

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us? ( instagram, google, facebook etc..)

Have you had a facial before?

What are your specific skincare concerns?

*If you have acne: I understand Skin Theory's corrective facials will only help clear out congestion and some current blemishes. It will not prevent future congestion or blemishes. If you need help clearing acne, we have an acne program and can schedule you for a acne clearing program first time consultation at a later date.

Any other reasons for a facial besides your concerns?

Give us an idea of what you typically use on your skin daily?

Any known allergies?

Skin Theory uses products in our facials that may contain tree nuts, gluten and dairy or have been manufactured in a plant with these ingredients.

Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

Do you smoke?

Are you undergoing any hormone replacement therapy?*

Are you currently on any blood thinners?*

Do you release consent for your photos to be used for social media/marketing purposes?*

Are you currently using any products that contain:

Do you currently have any rashes, itching or underlying redness on your face?

Please list medications or supplements you are currently taking.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you had botox in the past 7 days?

Have you had fillers in the past 14 days?

Please make sure to include a photo of your AM/PM routines. Thank you

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

Are you taking birth control?

Are you pregnant or breast-feeding?

SERENE SKIN BY WANSADA
Facial Treatment Acknowledgement, Consent & Waiver
ACKNOWLEDGEMENT AND WAIVER
I understand that my facial treatment may include professional-strength skincare products, enzymes, chemical exfoliants or peels, and other treatment modalities as appropriate for my skin and treatment goals. These modalities may include, but are not limited to, microdermabrasion, steam, extractions, nano infusion, LED light therapy, high-frequency, and other cosmetic facial techniques.

I understand that facial treatments are cosmetic services and that no medical claims are expressed or implied. I understand that achieving optimal results may require multiple treatments and that following the recommended home-care and maintenance protocol is important.

I understand that there are no guarantees regarding the results of any treatment. Results may vary depending on many factors, including age, skin condition, lifestyle, sun exposure, smoking, climate, genetics, and adherence to recommended home care. I understand that I may or may not experience visible peeling following a peel or exfoliating treatment, as each person's skin responds differently.

I understand that some treatments may cause temporary discomfort or sensations, including stinging, prickling, warmth, hotness, tightness, sensitivity, redness, or mild irritation.

I understand that an esthetician is not qualified to diagnose, prescribe medication for, or medically treat any disease, illness, or medical condition. A facial or cosmetic treatment is not a substitute for medical diagnosis or treatment by a qualified healthcare professional.

I understand that although complications are uncommon, adverse reactions or complications may occur. If I experience an unexpected or concerning reaction, I agree to contact my Service Provider promptly and, when appropriate, seek medical attention.

I have voluntarily elected to receive cosmetic treatments at Serene Skin by Wansada after the nature, purpose, expected benefits, risks, and possible complications of the treatment have been explained to me. I have had the opportunity to ask questions and have received satisfactory answers.

Although it is not possible to list every potential risk or complication, I acknowledge that I have been informed of the reasonably foreseeable benefits, risks, and potential complications associated with my treatment.

PROFESSIONAL BOUNDARIES
I acknowledge that all services provided by Serene Skin by Wansada are professional cosmetic services and have no sexual intent.

I understand that appropriate professional boundaries must be maintained at all times. Any inappropriate touching, sexual behavior, harassment, or misconduct toward the Service Provider is strictly prohibited and may result in termination of the appointment and/or refusal of future services.

POST-TREATMENT CARE
I understand the importance of following all post-treatment care instructions provided by my Service Provider.

If I have questions or concerns regarding my treatment, home-care products, or post-treatment instructions, I agree to contact my Service Provider before using products or receiving additional treatments that may affect my skin.

I agree to refrain from tanning and excessive sun exposure while undergoing a treatment series and for at least 14 days following treatments when instructed by my Service Provider. I understand that direct sun exposure should be minimized and that daily broad-spectrum sunscreen of at least SPF 30 is recommended, or a higher SPF when appropriate.

MEDICAL HISTORY AND CONTRAINDICATIONS
I agree to disclose any medical condition, medication, allergy, skin condition, or other circumstance that may affect my treatment. This includes, but is not limited to:

Pregnancy or breastfeeding
Cold sore/herpes simplex history
Allergies or known sensitivities
Recent facial peels or exfoliating treatments
Recent laser treatments
Recent surgery or cosmetic procedures
Use of Accutane/isotretinoin or recent use
Prescription or over-the-counter medications that may affect skin sensitivity
Retinoids, Retin-A, or other exfoliating products
Steroidal medications
Hormone therapy
Any other condition or medication that may affect healing or skin sensitivity
I understand that I should not discontinue any prescribed medication without first consulting the prescribing healthcare professional. I understand that certain medications or medical conditions may require postponement or modification of my treatment.

I agree to inform my Service Provider of any changes to my health, medications, skincare routine, or medical history before future treatments.

RECENT TREATMENTS
I confirm that I have disclosed any recent chemical peel, laser treatment, microneedling, waxing, injectable treatment, surgery, or other cosmetic procedure that may affect my skin.

I understand that I should not receive another exfoliating, peeling, or corrective treatment until my skin has adequately recovered and my Service Provider has determined that it is appropriate to proceed.

I agree to follow all aftercare instructions provided by my Service Provider.

PHOTOGRAPHS
I give permission for photographs to be taken for the purpose of documenting and monitoring my treatment progress.

I understand that treatment photographs may be kept as part of my client records.

Any use of my photographs for advertising, social media, website, educational, or promotional purposes requires my separate permission.

CLIENT RESPONSIBILITY
Prior to receiving treatment, I confirm that I have truthfully disclosed all relevant medical conditions, medications, allergies, skin conditions, recent procedures, and other information that may affect my treatment.

I agree to inform my Service Provider of any changes in my medical history, medications, skincare products, or other information relevant to my treatment before future appointments.

I understand that withholding information or providing inaccurate or incomplete information may increase the risk of contraindications, adverse reactions, irritation, or other complications.

I understand that I am responsible for consulting a qualified physician or other appropriate healthcare professional regarding any medical condition, disease, illness, or concern that is outside the scope of cosmetic esthetic services.

TREATMENT CONSENT
By signing this form, I consent to receive appropriate professional cosmetic treatments offered by Serene Skin by Wansada, which may include, depending on my individual consultation and treatment plan:

Bespoke Facial Treatments
Barrier-Recovery Treatments
Firming and Peptide Treatments
Custom Corrective Peels
Light Chemical Peels
Signature Facial Treatments
Extractions
Microdermabrasion
Nano Infusion
LED Light Therapy
High-Frequency
Steam
Other appropriate cosmetic facial modalities
I understand that not every treatment or modality listed above will be appropriate for me. My Service Provider may modify, postpone, or decline a treatment when it is determined that doing so is in the best interest of my skin and safety.

I understand that I am receiving professional cosmetic services from a qualified/licensed Service Provider, as applicable under state law.

I understand that Serene Skin by Wansada and its Service Providers do not diagnose, prescribe, or medically treat illness, disease, or other medical, physical, or mental health conditions. I am responsible for consulting an appropriately qualified healthcare professional for medical concerns.

RELEASE AND LIABILITY
I understand that cosmetic treatments involve inherent risks and that individual results vary.

To the extent permitted by applicable law, I agree to release and hold harmless Serene Skin by Wansada and its Service Providers from claims, expenses, damages, or liabilities arising from my treatment, except where prohibited by law or resulting from negligence or other conduct for which liability cannot legally be waived.

I understand that Serene Skin by Wansada cannot be responsible for complications or adverse reactions resulting from information that I failed to disclose, inaccurate information that I provided, failure to follow post-treatment instructions, or failure to disclose changes in my medical history, medications, or skincare routine.

CONFIDENTIALITY AND CLIENT INFORMATION
I understand that my personal information and treatment records will be kept confidential and handled in accordance with applicable privacy laws and business policies.

I confirm that all information provided on this form is true and accurate to the best of my knowledge.

COMMUNICATION CONSENT
By signing this form, I consent to receive communications from Serene Skin by Wansada by text message and/or other contact methods I have provided.

These communications may include appointment confirmations, appointment reminders, scheduling information, treatment follow-ups, business updates, and other information related to my services.

I understand that I may request to opt out of non-essential communications at any time, subject to any applicable legal or transactional communication requirements.

CLIENT ACKNOWLEDGEMENT
I have read this consent and waiver form carefully and understand its contents.

I have been given the opportunity to ask questions regarding my treatment, including its nature, purpose, benefits, risks, possible complications, and aftercare requirements.

All of my questions have been answered to my satisfaction.

I voluntarily consent to receive cosmetic services from Serene Skin by Wansada and understand the information provided above.

*PLEASE REFRAIN FROM USING RETINOL, DIFFERIN, AND RETIN-A 2 WEEKS PRIOR TO YOUR APPOINTMENT.

*PLEASE DO NOT USE ANY FACIAL SCRUBS / EXFOLIANTS 1 WEEK PRIOR TO YOUR APPOINTMENT.

*IF YOU ARE CURRENTLY ON ACCUTANE OR WERE RECENTLY ON ACCUTANE, PLEASE CONSULT YOUR DOCTOR BEFORE SCHEDULING YOUR APPOINTMENT.

Date of Facial Appointment:

Date

Signature

Facial health Intake Form

Your Skin

Your Medical History

Females Clients