Facial Consent – Celebrity Skin Studio

Date*

Name*

First Last

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Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Current Age*

How can I best help you with your skin care concerns today?*

Occupation/Work Environment*

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.

Stress Level*

On a scale of 1-10 with 10 being the highest, please indicate your current stress level.

Check any of the skin care concerns you would like to improve*

Check all that apply

Fine Lines/Wrinkles
Pigmentation/Dark Spots
Acne Scars
Reduction of Redness
Reduction of Oil or Acne
None of the Above

Have you had a facial before*

Yes
No

If yes, when was your last facial

What is your current skin care routine?*

What are you currently using on your skin, include any professional or drug store products you use.

Which Skin Conditions best describes your skin?*

Check all that apply

Oily
Acne
Dry/Dehyrated
Rosacea/Redness
Normal

Smoking History*

Check all that apply

I do not smoke and have never been a smoker
Previous smoker
Live with a smoker
I currently smoke

Allergies*

LIst any allergies you may have, include medications, seasonal, environmental etc. If none list N/A

Have you been treated for any of the following?*

Please check all that apply

Cancer
Acne
Skin Disease
Diabetes
Depression
Blood Pressure
None of the above

If you checked any boxes above please provide information

List when and what type of treatment you received

List any other medical conditions here if none list N/A*

List any Medications if none list N/A*

Remember to list birth control if applicable

Are you prone to cold sores?*

Yes
No

Pregnancy or Hormone Treatments*

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

Water Intake*

Approximately how many ounces of water do you drink daily?

LIst any vitamins or suppliments you take. If none list N/A*

Do you excercise?*

Please indicate yes or no and if yes, how often

Have you had any recent Skin Care or Cosmetic procedures?

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.

Is there anything else I need to know to provide you with a safe and relaxing experience?

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

Please read, sign and date below*

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.

By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver

Signature*

Date*