Facial Consent Form

Name *

Date * +

Address: *

City & State: *

Zip Code: *

Birthdate: *

Phone: *

Email: *

Occupation: *

Medical History *

Accutane

Arthritis

Epilepsy

Fever Blisters

HIV

Lupus

Plastic Surgery

Psoriasis

Vitamins

Rashes

Warts

Acne

Depression

Diabetic

Eczema

Hepatitis

Insomnia

Pregnant

Retin-A

Seborrhea

Shingles

Other: ______________________________________

Allergies:________________________________

Any Metals in Body

Heart Condition

Pacemaker

Blood Pressure (high/low) _______________

Hyper/Hypo Pigmentation

Hyper/Hypo Thyroid

Medications: __________________________________

Planning on Getting Pregnant

Skin Cancer

Surgeries: ______________________________________________________

Personal Skin Care History *

What is your main reason for being here today? *

What skin type and/or problem do you feel you have? *

Have you ever had a facial treatment before? If yes, when and where? Was it a beneficial experience? *

Have you ever had a reaction to a food, cosmetic, or skin care product? If yes, please give details: *

Where do you purchase most of your face and body care products? *

How much time do you spend on your daily skin care/makeup routine? *

How do you feel about your skin conditions? What would you like to improve? *

Do you tend to tan or burn? *

Do you smoke or drink? How often? *

Do you exercise and how often? *

How much sleep do you get per night? *

Are you interested in long term or short term spa treatment? *

Are you pleased with your current products? *

Have you ever been waxed? *

I, the undersigned, confirm that: *

1. We do not wax anyone on accutane, retin-a, or other medications/products that exfoliate or thin the skin. We do not wax anyone undergoing chemotherapy or radiation treatments.

2. We will not treat clients with questionable medical conditions such as Herpes Simples (cold sores, fever blisters), open wounds or sores, healing incisions, infectious diseases, etc. We do not massage clients undergoing cancer, diabetes, or systematic treatments or any other specific contra-indications for the body.

3. We require a minimum of 24 hours advance cancellation notice. Any client giving less will be charged up to 100% of the service price.

4. I understand that services received here are not a substitute for MEDICAL CARE and any information provided by the technician is for educational purposes only.

6. All information received by the client on this chart, is completely private and confidential.

7. We do not give cash refunds.

8. Defective products must be returned within ten (10) days of purchase to receive credit.

9. Gift certificates are non-refundable and must be used within a year to avoid monthly inactivity fees.

10. ALL SALES ARE FINAL.

Client Name: *

Date * +

Signature *

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