Facials & Body Treatments Consent Form

Facials & Body Treatments Consent Form
Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Address:
Cell Phone Number:
Any Health Problems or Recent Surgeries? If so, please describe:
Do you have any allergies? If so, please describe:
Are you currently, or have you used Retin-A, Renova, Resorcinol, or any powerful AHA or any other drug thinner products within the last 3 months?
Are you currently using or taking Accutane?
Have you experienced Botox, Restylane or Collagen Injections?
When is the last time you've exfoliated?
Are you a diabetic?
Do you use a tanning bed?
Are you exposed to the sun daily or will you spend more time out in the sun anytime soon?
Are you under the care of a dermatologist?
Please check any of the following conditions you have experienced?

PacemakerMetal PlateCold SoresType option 4LupusCancerSeizuresWartsAsthmaSkin infectionsEasy BruisingAccident or traumaAnemiaHigh/Low Blood PressureHeadachesPregnant
If any of the above is checked, please explain
What are your skin concerns and challenges?
What goal would you like to get accomplished today?
Feel free to provide any additional comments here:
I understand, have read and completed this questionare truthfully. I agree that this consititues full disclosure, and that it supresed any previous verbal or written disclosure. I understand that witholding information or providing misinformation may result in contraindication and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release the esthetician from liability and assume full responsibility thereof.
Signature

Clear
Esthetician's Name: E'jaleigh Nicholson
Should be Empty: