Facial Treatment Consent Form

Facial Treatment Consent Form

Facial Treatment Consent Form
Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Age:
Gender

FemaleMaleNB
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Medical Inforamtion

Please check any of the following that apply to you:
PregnantNursingSkin allergiesAllergies to specific ingredients or products
Medical conditions:
Recent Facial Surgeries or Treatments:
Other Medical Concerns

Skin history

Please check any of the following that application to you:
Type a question

OilyDryCombinationSensitiveAcne-ProneAging
Other:
Current Skincare Routine (Products, Frequency, Concerns or goals)

Consent and agreement
I understand that the facial treatment is not a substitute for medical treatment or advice. I have provided accurate information to the best of my knowledge. I consent to the facial treatment and agree to the follow the technichian's recommendations for aftercare and skincare.
Signature
Date

MonthDayYear
Date
Should be Empty: