Facial Consultation Form - Vanilla Studio

Date

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

What are your specific concerns at this time regarding your skin?

What is your stress level right now?

What do you consider your skin type?

What is your daily skin care regimen?

What is your goal for this session?

Please check all that apply.

Have you ever received professional skin care treatments or massage?

Preferred Massage Pressure?

Massage Preferences (Select 2):

During your service, do you prefer:

Date

Signature

By SUBMITTING THIS FORM, I agree to the following:

1) I give my permission to receive facials services.
2) I understand that facial or facial massage is not a substitute for traditional medical treatment or medications.
3) I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications.
4) I have clearance from my physician to receive facials or dermaplane.
5) I understand the risks associated with facials include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Vanilla Studio from all liability concerning these injuries that may occur during the facial session.
6) I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risksbased on my physical condition.
7) I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly.
8) I understand that I or the esthetician may terminate the session at any time.
9) I have been given a chance to ask questions about the session and my questions have been answered.