Facial Treatment Consent Form

Facial Treatment Consent Form

Please complete this form to provide your consent and help us tailor your facial treatment at Crowned By Catherine .
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about us?
If referred, by who?
Are you currently under the care of a physician?
Have you experienced any of these health conditions in the past or present?

Other
Any known allergies?

Other
If 'Other', 'Fragrance', or 'Food' was selected above, please list any specific known allergies:
List medications/supplements you are currently taking:
Have you ever received any botox or fillers? If so, where and when?
Have you ever experienced claustrophobia?
Please rate your stress level.

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
What do you do for a living?
What would you say your skin type is?
What are your skin concerns?

Other
Do you have any known skin conditions? (Ex: dermatitis, vitiligo)
What skin care products do you use on a daily basis?
What skincare brand(s) do you use?
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:

Other
Are you currently using any products that contain:
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Do you:
How often are you outside or in the sun?
Are you taking birth control? (Female clients only)
Are you pregnant or breast-feeding? (Female clients only)
Signature
Should be Empty: