• Client Questionnaire & Consent Form

    Facial Treatment
  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical History

  • Are you currently taking any medications?*
  • Do you have any allergies to cosmetics, food or drug?*
  • Are you currently pregnant, nursing or trying to conceive?*
  • Please check if you are affected by or have any of the following*
  • Are there other health/skin concerns we should be aware of?*
  • Have you had a reaction from a product/treatment on your face?*
  • Have you gotten recent treatments within the past few months? Ex: Botox, Laser Hair Removal, Tanning Beds, etc.*
  • Have you had a facial treatment before?

  • Skin Concerns & Homecare

  • Rows
  • Rows

  • Treatment Preferences

  • Music Preferences
  • Talking Preferences
  • Bed Warmth Preference
  • Aromatherapy Preferences
  • Scalp/Hair Touch Preference
  • Do you give permission to be filmed or have photos taken of your treatment?
  • Is there anything else we should know about you, your preferences or your skin?

  • Acknowledgement & Release

    By signing this form, the client agrees to the following: I understand, have read, and completed this questionnaire, truthfully and agree to inform the technician of any changes in the above information. I agree that this constitutes full disclosure and that it supersedes any previous verbal or disclosures. I understand that withholding information or providing this information may result in contraindications and or irritation to the skin from treatments received. The treatments I received here are voluntary and I release this institution and or skincare, professional from liability and assume full responsibility there of. I am aware of the policies and am compliant to paying cancellation, late & no show fees if needed.
  • Date*
     - -
  • Should be Empty: