Facial Consent

  • Date Format: MM slash DD slash YYYY
  • Please tell me about your occupation and work environment,. For example if you work outside, if you have to wear a mask at work, if you are exposed to things like steam, heat, chemicials etc. If you are a student or unemployed please include that.
  • On a scale of 1-10 with 10 being the highest, please indicate your current stress level.
  • Check all that apply
  • What are you currently using on your skin, include any professional or drug store products you use.
  • Check all that apply
  • Check all that apply
  • LIst any allergies you may have, include medications, seasonal, environmental etc. If none list N/A
  • Please check all that apply
  • List when and what type of treatment you received
  • Remember to list birth control if applicable
  • Are you pregnant, trying to get pregnant or having any Hormone Therapy (for Pregnancy or Menopause) please list details. If none of the above list N/A
  • Approximately how many ounces of water do you drink daily?
  • Please indicate yes or no and if yes, how often
  • List any medical or cosmetic procedures such as injections, resurfacing treatments/laser or chemical peels, surgeries etc. that have been received within the last year. It is important to keep your technician updated on any procedures received.
  • PRE & POST Instructions

  • PRE appointment instructions: If possible arrive with no make up on, feel free to wear something comfortable if you like. It is best to complete any tasks such as working out etc that may make you sweat prior to your treatment as you will want to relax and let products penetrate into the skin after treatment. POST Treatment: In some cases inflamation may be present from extratctions. Avoid sweating or doing activities that would make it necessary to have to wash your face after your treatment. For best results it is recommended to let the products from your facial absorb into the skin and wash your face the next morning. Follow you esthetician's recommended skin care regimen for optimal results.
  • Consent for Treatment and Liability Waiver

  • I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.
  • Date Format: MM slash DD slash YYYY