Consent for Facial Treatment
PLEASE PRINT LEGIBLY
ALL INFORMATION WILL BE KEPT CONFIDENTIAL
Name: ___________________________ Phone: Home _______________Work _____________ Cell
_____
Address: _________________________________________________ City/State/Zip: ____________________________
E-mail:______________________________
Date of Birth: ___/___/_ Occupation: ________________
Emergency Contact: _______________________
Relationship:
__________ Phone: _______________
Referred by: □Internet □SpaFinder □SpaWish □Direct Mail □Other: _____________
__________
_____
Would you like to receive occasional e-mail promotions?
❍Yes
❍No
HEALTH HISTORY
Please help us ensure a safe a comfortable facial experience by providing the following information. Please answer the
questions to the best of your knowledge.
Have you ever had a facial treatment before?
❍Yes
❍No
Date of last facial:
❍Yes
Are you currently under a physician’s care for any skin condition?
❍No
If yes, please explain:
How many ounces of water do you drink per day?
Check all that apply.
❍ Back/Neck Problems
❍ Headaches/Migraines
❍ Skin Infections/Disorders
❍ Sinus Problems
❍ Cancer History
❍ High or Low Blood Pressure:
❍ TMJ Dysfunction, Jaw Pain
❍ Stroke History
If any condition that you have marked above needs to be detailed or if there is anything else to share, please do so:
Are you currently taking any medications?
Female Clients Only:
Are you taking oral contraceptives?
❍Yes
❍Yes
❍No
❍No
If yes, please list:
If yes, please list:
Any recent changes to or from your contraceptive treatment?
Are you undergoing any hormone replacement therapy?
❍Yes
❍Yes
❍No
❍No
If yes, what and when:
If yes, please specify:
CURRENT AND PAST SKINCARE TREATMENTS/SERVICES
Check all that apply.
❍ Accutane
❍ Facial Waxing
❍ Facial Cosmetic Surgery
❍ Microdermabrasion
❍ Chemical Peels/Photofacials
❍ Injectables/Dermal Fillers
❍ Laser Treatments
❍ Oral/Topical prescription medication
If any condition that you have marked above needs to be detailed or if there is anything else to share, please do so:
SELECT ALL SKIN CONDITIONS THAT APPLY:
❍ Tendency towards redness
❍ Skin breakouts
❍ Sun Damage
❍ Sunburn/blush easily
❍ Oily during day
❍ Dry Skin
❍ Aging skin-fine lines/wrinkles
SELECT ALL PAST REACTIONS/ALLERGIES THAT APPLY AND EXPLAIN
❍ Cosmetics:
❍ Enzymes:
❍ Foods:
❍ Fragrance:
❍ Glycolic/Lactic Acid:
❍ Iodine:
❍ Medicine:
❍ Salicylic Acid:
❍ Sunscreens:
If any condition that you have marked above needs to be detailed or if there is anything else to share, please do so:
What are your skincare goals?
Select all products you are currently using?
 Vitamin A/Retinol Derivatives
 Glycolic/Lactic Acid
 Exfoliating Scrubs
 Any Hydroxyl Acid Product
Do you have a daily skincare regimen?
❍Yes
❍No
I understand that I may have some discomfort, redness and swelling for 2 hours to 7 days, itching or irritation, skin peeling or flaking for up to 7 days after the
procedure and I could have possible scarring as a result. It is your responsibility to inform the esthetician of any pre-existing conditions, limitations or specific
sensitivities and to inform your esthetician if you feel any discomfort during the session. If you do experience discomfort, please ask the esthetician to adjust
the process. You understand and voluntary accept any risks which you have been advised about associated with your facial, or from any use of the
company’s facilities, services or products and you herby release ReNew Therapeutic Massage Inc. (including its employees, practitioners, agents, and
insurers) from all liability for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you resulting
therefrom. You further hereby release all of the foregoing personnel and entities from all liability arising from any such injury or damage resulting from your
failure to disclose any pre-existing condition(s), limitation(s), or specific sensitivities, or your failure to inform your esthetician of any discomfort during the
session. Your esthetician may determine that it is unsafe for you to proceed with or continue a treatment due to health related concerns/contraindications. In
this event you may be required to provide ReNew Therapeutic Massage Inc., with a physician’s medical release prior to continuing treatment. The
undersigned acknowledges that he/she has read this agreement.
CANCELLATION POLICY:
We respectfully ask that you give the Center a minimum of 24 hours notice if you must cancel or reschedule an appointment. This courtesy makes it possible
to give your reserved time to another client. The full service(s) cost will be charged for any appointment(s) cancelled less than 24 hours or no-shows. Please
note that appointments made the same day are subject to our cancellation policy as well.
Client Signature:
Initials:
Date: ________/_______/_______
Thank you for choosing ReNew Therapeutic Massage & Wellness Center!
DO NOT WRITE BELOW THIS LINE – OFFICE USE ONLY
FACIAL WELLNESS CHART
CLIENT NAME:
D.O.B.:
/
/
 Reviewed Medical History/Contraindications/Allergies
Changes:
Skincare Goal:
Facial:
Recommended homecare products:
 Reviewed aftercare instructions on FWP
Esthetician Initials:
Esthetician Name:
Esthetician Signature:
ReNew Therapeutic Massage Inc.
6263 Executive Blvd ● Rockville, MD 20852 ● Tel: 301-230-6555
Date:
/
/
.