FACIAL CONSENT FORM Facial Consultation Form Please note that the following personal, medical, and skin history is essential for your aesthetician to execute appropriate treatment procedures and not doing so, expected results may be affected. Name * First Name Last Name DOB * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * How did you hear about us? Friend/ Relative Internet Search Social Media Other Emergency Contact Name/ Contact Number: What is your main reason for visiting today? SKIN CONCERNS Please select all that apply: Age spots Broken capillaries Sensitive skin Cyst Whiteheads Pimples/ Pustules Blackheads Oily Skin Dehydrated Skin Pigmentation/ Melasma Flaky Skin Lines/ Wrinkles Dry Skin Please specify if other: Does your skin breakout? Nerver Rarely Frequently Always Have you ever been diagnosed with rosacea? Yes No If so, do you know which type? Do you use Tanning booths or artificially tan? Yes No CURRENT ROUTINE Please list the name of any products you are currently using: LIFESTYLE Which of the following best describes your skin type? Type I: Fair skin tones—Always burns, never tans Type II: Light skin tones—Burns easily, tans slightly Type III: Fair to olive skin tones—Burns moderately, tans moderately Type IV: Light brown skin tones—Burns slightly, tans easily Type V: Dark brown skin tones—Rarely burns, tans easily Type VI: Dark brown skin tones—Rarely burns, tans easily Do you wear sunscreen daily? Yes No Do you have difficulty sleeping? Yes No Do you smoke tobacco/ marijuana/ vape? Yes No How many times per week do you exercise? Please rate your current stress levels Low Moderate High Very High Please rate your weekly alcohol intake Low Moderate High None Please rate your daily water intake Low Moderate High Very High How many hours do you spend outdoors per week, on average? (Including gardening, exercise, leisure, sports, work, etc.) 1 - 3 4 - 6 7 - 9 10+ Are you aware of any hormonal imbalances? Are you pregnant or trying to become pregnant? Yes No Do you regularly eat any of the following? Please check all that apply Dairy products White Bread Cacao/ Cocoa Seaweed Dinning out Sushi Fast Food/ Takeout Kelp Kombucha Pasta Dates TREATMENT HISTORY Have you had Chemicals Peels, Laser Treatments, or Microdermabrasion? Within the last month Within the last year Never Have you had Check all that apply: Chemicals Peels Microdermabrasion Laser Treatments Dermal Fillers Anti-wrinkle Injections Skin Cancer Removal Treatment If so, which treatment did you have and how frequently? MEDICAL INFORMATION Are you currently under a dermatologist or specialist care Yes No If yes, please list the treating specialist name: Condition being treated/ monitored: Allergies Latex Yes No Skin Care allergies/ reaction Yes No Sulphur Yes No Please list any other known allergies you have: Do you suffer from any of the following: Epilepsy Eczema/ Dermatitis Psoriasis PCOS Cold Sores Autoimmune Disorder Have you ever or are you taking any of the following (within the last year): Antibiotics for acne Thyroid Medication Antihistamines Birth Control Retin A Oral Tretinoin Oral Steroids Please list all current herbs/ vitamins/ supplements you take: CONSENT FORM I certify that I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof. * I Agree I Disagree Client Name First Name Last Name Signature * Date MM DD YYYY If client is under the age of 18, parent/ guardian consent is needed: First Name Last Name Signature Todays Date MM DD YYYY Thank you!
