Under-18 Facial Treatment Consent Form
Client Information
Client Name:
Date of Birth:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Age:
Parent/Guardian Name:
Phone Number:
Format: 00000000000.
Email:
example@example.com
Medical & Skin Information
(Parent/guardian may complete with the client)
1. Does the client have any known allergies (including skincare ingredients)?
No
Yes
If yes, please list:
2. Does the client have any skin conditions (e.g., eczema, acne, dermatitis, psoriasis)?
Yes
No
If yes, please describe:
3. Is the client currently using any prescribed skincare or medication (e.g., acne treatments, retinoids, antibiotics)?
Yes
No
If yes, please list:
4. Has the client recently had any cosmetic treatments (e.g., peels, waxing, laser)?
Yes
No
If yes, please describe:
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Treatment Information
I understand that:
The facial treatment is for non-medical, cosmetic purposes only.
The therapist will assess the client's skin and choose suitable products.
Some temporary reactions may occur, such as redness, tingling, or sensitivity.
The therapist will stop the treatment if the client feels discomfort.
Results vary depending on skin type and condition.
Parent/Guardian Consent
I confirm that:
I am the legal parent/guardian of the above-named client.
I give permission for them to receive a facial treatment.
I have disclosed all relevant medical and skin information.
I understand the nature of the treatment and possible temporary reactions.
I agree that the therapist may refuse or adjust the treatment if necessary for safety.
Parent/Guardian Signature:
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Client (Under-18) Agreement
I understand the treatment and agree to let the therapist know if anything feels uncomfortable.
Client Signature:
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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