Client Consent Form

Client Consent Form
Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Do you have any of the following conditions? If yes, please select them:

CancerMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresHIV AIDSHepatitis A/B/CDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilyLupusKeloid ScarringBlood Clot DisorderMenopauseFever Blisters/Cold SoresOther
Please List Supplements
Please List Medications
Have you been on/or currently on Accutane?

CurrentlyWithin 6 monthsOver 6 monthsNever
Please List Prior Surgeries
Skin condition

NormalOilyDryAcneOther
How does your skin heal?

FastPigmentsScarsSlowOther
Are you pregnant?

YesNo
Are you trying or planning to be pregnant?

YesNo
Are you nursing?

YesNo
If Applicable, what Birth Control or Hormones are you prescribed?
What facial products you're currently using?
What tools/ facial enhancements do you use?

LEDCold RollerFacial MasquesNone
Have you ever had an allergic reaction to a topical product or procedure? If so, what product/ingredient/procedure?
Would you like to target any skin concerns on your body?

Back/ Chest AcneGlute AcnePost procedure scarringKeratosis PilarisPigmentationOther

Diet: Do you consume any of the following?

Do you consume alcohol?

YesNoOccasionally
Do you smoke?

YesNoOccasionally
What is your average stress level

LowModerateHigh
What is your average nightly sleep?

4-5 Hours5-6 Hours7-8 HoursI work night shifts
Do you swim in a chlorinated pool?

YesNo
Do you use a fabric softener or dryer sheets?

YesNo
What is your primary skin goal?
What is your secondary skin goal?
What is your skincare routine budget? A fully customized routine ranges $200-$800.

Under $200$200-$300$300-$400Flexible Budget
Eyelash Lift/ Eyebrow Lamination
Have you had an Eyelash Lift or Eyebrow Lamination before?

YesNo
Have you ever had an allergic reaction to a product around your eye?

YesNo
If yes, What Product?
Have you ever had a reaction to Thioglycolic Acid

YesNo
Do you have an allergy to medical tape?

YesNo
Terms & Conditions
I understand that my data will be strictly confidential. Aesthetics Refined does not share information.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

I understand all appointments must be cancelled or rescheduled outside of a 24 hour window, or a 50% service charge will be placed on the credit card on file.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Eyelash Lift/ Eyebrow Lamination