BEAUTY KULTURE STUDIO & ACADEMY FACIAL TREATMENT FORM

BEAUTY KULTURE STUDIO & ACADEMY

FACIAL TREATMENT CONSENT FORM
Name*

First NameLast Name
Email*
example@example.com
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Occupation:
Referred by:*
Emergency Contact & Number*
Do you have any health problems or concerns that I need to be aware of before treatment, If the answer is yes, please describe?
Do you have any allergies?*

YesNo
If yes, please list all allergies:
Any recent surgery on your face, neck, and shoulders?*

YesNo
Are you currently, or have you used Retin-A, Renova, Resorcinol, or any powerful alpha hydroxyl Acids within the past 3 months?*

YesNo
If YES, please explain:
Are currently using or taking Accutane?*

YesNo
Are you using any other skin thinning products or drugs? If YES, list and describe product:
Are you a diabetic?*

YesNo
Do you use a tanning bed?*

YesNo
Are you exposed to the sun daily or will you spend more time out in the sun anytime soon?*
Do you currently wear contact lenses?*

YesNo
Have you experienced Botox, Restylane or Collagen injections? If YES, please list and explain:*
Please select the following conditions you have/had experienced?

Pacemaker or pins in bonesMetal plateCold soresWartsLupusHigh/Low blood pressureCancerAnemiaEpilepsyHepatitisAsthmaSeizuresStrokeHeadachesPregnantEasy bruisingSkin infectionsAccident or trauma
Please select that following that best describes your skin type:*

Burns EasilyNever Tans, Always BurnsTans Slightly, Burns ModeratelyTans Gradually, Seldomly BurnsAlways Tans, Rarely BurnsDeep Tan, Never BurnsDeeply Pigmented
Are you under the care of a Dermatologist?*

YesNo
What are your skin concerns and challenges?*
Signature*

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