Facial Consultation & Consent Form

Facial Consultation & Consent Form

Thank you for choosing New Moon Esthetics! Please complete this consultation form before your facial appointment. The information you provide helps me select appropriate products and treatments based on your skin’s current condition and goals. Please answer all questions honestly and completely. If anything changes after completing this form, please inform your esthetician before your next treatment.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
YOUR SKIN
What are your primary skin concerns?

Other
How would you describe your skin
Have you ever experienced any unusual skin reactions to skincare products or professional treatments?
If yes, please explain
Do you have any known allergies or sensitivities?
If yes, please list:
CURRENT SKINCARE
Are you currently using any prescription or professional skincare products?
If yes, please list the products:
Are you currently using any of the following?
How frequently do you exfoliate your skin?
MEDICAL AND TREATMENT HISTORY
Are you currently pregnant or breastfeeding?
Are you currently taking any medications or supplements that may affect your skin or make you photosensitive?
If yes, please list:
Have you used Accutane/isotretinoin within the past year?
Have you had any recent professional skin treatments?
If yes, please select:

Other
Date of most recent treatment:
Do you currently have or have you recently experienced any of the following?
Please explain anything you selected:
FACIAL TREATMENT
Which service are you receiving:
Which enhancements are you receiving ?
CLIENT CONSENT
I understand that facial treatments are customized according to my skin’s condition, needs, and goals at the time of my appointment.I understand that temporary redness, sensitivity, dryness, mild irritation, or breakouts may occur following certain facial treatments.I understand that extractions, exfoliation, enzymes, masks, high frequency, and other professional treatments may cause temporary skin sensitivity. I understand that results vary from person to person and that no specific result can be guaranteed.I have provided accurate and complete information regarding my health, medications, skincare products, allergies, sensitivities, and previous treatments. I agree to inform my esthetician of any changes to my health, medications, skincare routine, pregnancy/breastfeeding status, or skin condition before receiving future treatments. I understand that my esthetician may modify, postpone, or decline a treatment if my skin or health history indicates that the treatment may not be appropriate or safe at that time. I understand that failure to disclose relevant medical, medication, skincare, or treatment information may increase my risk of an adverse reaction. I have had the opportunity to ask questions regarding my treatment and understand the information provided to me. I acknowledge that I have read and understood this Facial Consultation & Consent Form and voluntarily consent to receive facial services from Neu Moon Esthetics
ACKNOWLEDGEMENT
I confirm that the information provided in this form is accurate to the best of my knowledge.

I understand that I am responsible for communicating any changes in my health, medications, skincare products, allergies, or skin condition before receiving future treatments.
Client Name:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Facial Consultation & Consent Form

YOUR SKIN

CURRENT SKINCARE

MEDICAL AND TREATMENT HISTORY

FACIAL TREATMENT

CLIENT CONSENT

ACKNOWLEDGEMENT