Consent form – Facials Date Name Does your job require that you work outdoors?YesNo What would you like to achieve from your skin today? Which of the following best describes your skin? Creamy complexion - always burns easily, never tansLight complexion - always burns, tans slightlyLight/ matte complexion - burns moderately, tans graduallyMatte complexion seldom burns, always tans wellBrown complexion rarely burns, deep tanBlack Complexion - never burns, deeply pigmented Do you have any special skin problems or concerns pertaining to your face / body? If yes, Please specify. Have your ever had chemical peels, laser or microdermabrasion?YesNo In the last month?YesNo Do you use Retin-A, Renova, Adaplene Hydroxyl Acid or Retinol/ vitamin A derivative products? If yes, Please specify Have you used acne medication?YesNo when and which drug? What skin care products are you currenlty using? List the brand if known Have you recently used any self- tanning lotions, creams or treatments?yesno Have you used any self-tanning lotions, creams or treatments? yes/ no? If yes, explain Have you used any of the following hair removal method in the past six weeks?YesNo Select the hair removal method you've used. check all that apply.ShavingWaxingElectrolysisPluckingTweezingStringingDepilatories Have you had any allergic reaction, or mention if you have had any allergies. What SPF do you use on your face? How often/ when Have you experienced Botox, Restylane or Collagen injections? Yes/no, If yes, explain. Female Clients only - Are you taking oral contraceptives?YesNo I understand, 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 recieve here are voluntary and I release this beauty spa and/ or skin care professional from liability and assume full responsibility thereof. Client's Signature Date Submit
