Client Consent Form

Client Consent

Evergreen Esthetics
Name:

First NameLast Name
Gender:
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Referred by:
Leave blank if not applicable
Reason for visit?
Just a few health questions

Please answer truthfully to the best of your knowledge
List all allergies:
Please list all current medications:
Piercings? Permanent Cosmetics?
If yes, please elaborate
Have you ever used any oral acne medications now or in the past?
If yes please list name of medication
Please check any condition that may apply

Other
If other please elaborate:
Have you ever had an adverse reaction to any skincare products? If yes please list and elaborate below:
Let’s Talk Skin

Please answer all questions truthfully and to the best of your ability.
How would you describe your skin?
What are your skincare concerns now?
Do you use any of the following?
Please list your AM and PM skincare routine. Please include brands.
Cleansers, Toners, Exfoliant, Serums, Moisturizer, SPF
Have you received any of the following?
If yes, please list when:
Are you currently under treatment for (acne, eczema, psoriasis etc.)
If yes elaborate if possible
If there is anything else you think I should know, please specify below:
Acknowledgement
Photo Release
Cancelation Policy
Terms and Conditions

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and or irritation to the skin from the treatment received. The treatments I receive here are voluntary and I release Gabrielle Garcia and Evergreen Esthetics from liability and assume full responsibility thereof.
Signature
Todays Date:

MonthDayYear
Date
Should be Empty:

Client Consent

Just a few health questions

Let’s Talk Skin

Acknowledgement