Facial Treatment Consent Form
Please complete this form to provide your information, medical history, and consent for facial treatment services.
Full Name
*
First Name
Last Name
Surname
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
City
*
Post Code
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
Have you had professional facial treatments before?
Yes
No
If yes, when was your most recent treatment?
Do you have sensitive skin or a history of reactions to skincare products?
Yes
No
If yes, please specify:
Have you used retinol, retinoids, exfoliating acids, or prescription skincare products in the past 7 days?
Yes
No
If yes, please specify:
Are there any open wounds, active breakouts, rashes, sunburn, or skin infections on your face?
Yes
No
If yes, please specify:
Do you currently have any skin conditions (acne, rosacea, eczema, psoriasis, dermatitis)?
Yes
No
If yes, please specify:
Do you have a history of cold sores or herpes simplex in the treatment area?
Yes
No
If yes, please specify:
Are you currently taking any medications that may affect your skin?
Yes
No
If yes, please specify:
Have you had any cosmetic procedures in the past 2–4 weeks (chemical peels, laser treatments, injectables)?
Yes
No
If yes, please specify:
Have you experienced adverse reactions to facial treatments in the past?
Yes
No
If yes, please specify:
Do you have a tendency to scar easily or experience delayed healing?
Yes
No
If yes, please specify:
Do you have any known allergies or sensitivities, including skincare ingredients?
Yes
No
If yes, please list:
Are you currently pregnant or breastfeeding?
Yes
No
If yes, please specify:
What are your primary skin concerns or goals?
Acne
Aging
Sensitivity
Pigmentation
Dryness
Texture
General maintenance
Additional notes or concerns:
Client's Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Signature (Consent)
*
Date (Consent)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practitioner Signature
Date (Practitioner)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I consent to the use of my photos and/or videos
I consent
I do not consent
Client's Signature (Photo/Video Release)
Date (Photo/Video Release)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Name (Payment Policy)
Client's Signature (Payment Policy)
Date (Payment Policy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Name (Cancellation Policy)
Client's Signature (Cancellation Policy)
Date (Cancellation Policy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent Form
Submit Consent Form
Should be Empty: