Skin Consultation & Consent Form
Please complete this form to help us provide a safe and customized spa experience. Your information will remain confidential.
Client Information
Please provide your personal details.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
HEALTH & SAFETY SCREENING
Please answer the following:
Do you have sensitive skin or any known allergies?
No
Yes
Details
Are you currently using Retinol, Accutane, or acne medication?
No
Yes
Details
Have you had any peel, laser, microneedling, Botox/filler, or waxing within the past 2 weeks?
No
Yes
Details
Do you currently have any rash, irritation, open skin, cold sore, or sunburn?
No
Yes
Details
Areyou pregnant, breastfeeding, or taking any medication that may affect yourskin?
No
Yes
Details
Recent treatments on face (last 4 weeks):
None
Peel
Laser
Microdermabrasion
Microneedling
Botox / filler
Hair removal (wax / thread / shave / tweeze)
CLIENT CONSENT
Please read and initial each item:
*
I confirm that the information above is accurate to the best of my knowledge. I understand that results may vary based on individual skin condition. I agree to inform the staff of any allergy, skin condition, medication, or discomfort before service.
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Consultation & Consent
Submit Consultation & Consent
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