Facial Consent Form

Name

First NameLast Name

Date Of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you currently under the care of a physician?

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

Any Known Allergies?

List medications / supplements you are currently taking.

Have you ever received any botox or filler? if so, when?

Have you ever experienced claustrophobia?

Please rate your stress level.

What are your skin concerns?

What would you say your skin type is?

What skin care products do you use on a daily?

Do you experience routine breakouts or acne?

Have you received any of these facial hair removal services in the last 7 days?

Do you currently use:

Please specify which product or type, if you answered YES to the question above

Are you currently using any product that contains:

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

Do you?

Are you taking birth control?

Are you pregnant or breast-feeding?

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Cloud Nine Esthetics and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Facial Consent Form

Your Medical History

Your Skin

Female Clients

Photo Release Form