Esthetician Consent Form ✨
Review and confirm your consent for the services you’re booking.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you received esthetician treatments before?
Yes
No
Do you have epilepsy or are prone to seizures?
Yes
No
Do you have any allergies? Please list any, including food and medications
Have you ever been treated for cancer? If so, please list when your treatment ended. (Treatments can compromise the skin)
Are you currently using any retinols? OTC or prescribed.
Do you have any metal implants?
Yes
No
What do you feel your skin type is?
Dry
Oliy
Combination
Sensitive
Which of the following best describes your skin?
Type I - Fair, burns easily, never tans, sensitive
Type II - Light skin tones, sometmes tans
Type III - Olive skin tone, always tans
Type IV - Darker skin tone sensitive
What skincare concerns do you have? Check all that apply
Dryness
Sensitivity
Redness
Acne
Pimentation
Fine lines
General Aging
What are your skin care goals?
Is there anything else you’d like to tell me?
General Facial Consent and Liability Form. Please check off to confirm you've read, understand and agree.
*
I have read and completed this questionnaire truthfully and to the best of my ability. I understand that withholding information and/or providing misinformation could result in irritations/reactions to the skin treatments received. the treatments I receive are voluntary and I release Becca Roberts and Dewey Studio from any liability. I consent that the answers provided are truthful and correct. I consent that I have not withheld any information that may be relevant to my treatment (s). I consent to all future services/treatments/appointments.
Cancellation/No show, Late and Child Policy. Please check off to confirm you've read, understand and agree.
*
If you need to cancel or reschedule, I kindly ask that you provide at least 24 hours’ notice. This gives me the opportunity to offer your appointment to another client.Appointments canceled with less than 24 hours’ notice, as well as no-shows, will be subject to a $100 cancellation fee.I understand that unexpected situations can happen, and I truly appreciate your understanding and cooperation. Thank you for helping me keep my schedule running smoothly. I look forward to seeing you at Dewey Studio!
Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Submit Consent
Submit Consent
Should be Empty: