First Time Client Consent Form
Client Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please take a moment to answer the following questions
Are you over 18 years old?
Yes
No
Are you currently taking any medications?
Yes
No
Please list
*
Are you pregnant or breastfeeding?
Yes
No
Do you have any allergies to cosmetics, food or drug?
Yes
No
Are you currently under a physician’s care?
Yes
No
Please specify
What skin care products do you currently use?
Cleanser
Toner
Antioxidant Serum
Eye Cream
Spot Treatment
Moisturizer
Sunscreen
Vitamin C Serum
Face Oil
Chemical Peel
Other
Please specify
Have you had skin cancer?
Yes
No
Do you use acne medication?
Yes
No
Are you taking oral contraceptives?
Yes
No
Please check if you are affected by or have any of the following
Asthma
Cardiac Problems
Herpes
Fever Blisters
Epilepsy
Skin Disease
Hepatitis
High Blood Pressure
Sinus Problems
Immune/ Autoimmune Disorders
Lupus
Eczema
Keloid Scarring
Bleeding Disorders
Recent Infection
Recent Surgery
Sunburn
Recent Laser/ Waxing
Hormonal or Thyroid Issues
Cancer
Diabetes
Dermal fillers in the last 2 weeks
I agree with
I understand my provider may refuse or modify treatment if it is not safe. If I experience any pain or discomfort during the session, I will immediately inform Tierra so that the products and/or technique may be adjusted to my level of comfort.
I understand there are no guarantees and results vary. Services are non-refundable once performed.
I further understand that facials should not be construed as a substitute for medical examination, diagnosis, or treatment.
I understand that my esthetician is not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
I agree to keep Tierra updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.
I consent to receive esthetic treatments and understand possible risks including redness, irritation, sensitivity, breakouts, or allergic reactions.
Also I understand that;
The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future
Client Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: