• Facial Consent Form

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • How did you hear about Grace Skin Studio?*

  • Medical History

  • Are you currently under treatment for any skin conditions?*
  • Have you experienced any of these health conditions in the past or present?*
  • Any known allergies?*
  • Have you ever experienced claustrophobia?*
  • Are you comfortable having a facial towel placed over the eyes and mouth for a brief moment to remove facial product?*
  • Are you comfortable having a cooling mask placed over the eyes during chest and shoulder massage?*
  • Regarding massage, please select which amount of pressure you would prefer:*
  • Regarding massage, please select any of the following you would prefer to NOT have massaged:*
  • If time and treatment allow, please select an area (or areas) of massage you would MOST like to focus on:*
  • If time and treatment allow, please select enhancements you would like added to your treatment:*
  • Are you sensitive to fragrance or essential oils used for aromatherapy purposes?*

  • Your Skin

  • What would you say your skin type is?*
  • What skin care products do you use on a daily basis?*
  • Do you experience routine breakouts or acne?*
  • Have you ever been diagnosed with eczema, psoriasis or rosacea?*
  • Have you received any of these facial hair removal services in the last 7 days?*
  • Do you currently use:*
  • Are you currently using any products that contain:*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?*
  • Please select any of the follow that apply to you:*
  • What is your goal for today’s visit?*
  • Are you okay with pictures or videos being taken for social media purposes?*
  • Are you taking birth control?*
  • Are you pregnant or breast-feeding?*

  • I do fully understand all the questions above and have answered them
    all correctly and honestly to the best of my ability. I understand that the services offered are not a substitute for medical care.
    I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding
    my treatment or suggested home product routine, I will inform my skin care professional immediately.
    I release and hold harmless the skin care professional and Grace Skin Studio from any liability for adverse reactions that may result from this treatment.

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