Sundara Day Spa
Signature & Advanced Facial Consent Form
Name: _____________________________
DOB: _____________
Esthetician: _______________________________
Date: ________________
Treatment: _________________________
Which conditions would you like to improve? (circle all that apply)
Hyperpigmentation
Sun Damage
Sugical/Facial Scars
Age Spots
Enlarged Pores
Acne
Stretch Marks
Scarring
Fine Lines & Wrinkles
Other: __________________________
Areas to be treated: ______________________________________________________________
Are you currently under a physicians care?
Yes
No
Reason: _______________________________________________________________________
Have you ever visited a dermatologist or other skin care specialist?
Yes
No
Reason: _______________________________________________________________________
Have you had a surgical procedure in the past 6 weeks?
Are you pregnant or planning to be?
Yes
Do you have a heart condition?
Yes
No
Do you have a thyroid disease?
Yes
No
Yes
No
No
Pacemaker
Do you have epilepsy or diabetes? (must have doctor note for treatment)
Yes
No
Please list any known allergies or sensitivities? _____________________________________
Please list any medications you are taking: _________________________________________
______________________________________________________________________________
Do you wear contact lens?
Yes
Do you have or ever had acne?
Do you smoke?
Yes
No
Yes
No
No
Do you have or ever had any of the following? (circle all that apply)
Keloid Scarring
Acne Scarring
HIV
Herpes Simplex
Hepatitis
Eczema
Dermatitis
Skin Cancer or Tumor
Other: _________________________________
Have you ever had any of the following treatments? (circle all that apply)
Chemical Peel
Laser Peel
Microdermabrassion
Restylane or Other Hyaluronic Acid Fillers
Glycolic Peel
Cosmetic Fillers
Botox
Juvederm
Cosmetic Surgery
Other similar treatments: __________________________ How long ago: __________________
Have you ever used any of the following products? (circle all that apply)
Retin A
Hydroquinone
Isotretinoin/Accutane
Other: ______________________________
How sensitve do you consider your skin to be? _______________________________________
To further help evaluate you skin, what do you consider your ethnicity to be? _________________
What products are you currently using? (circle all that apply)
Cleanser
Exfoliator
Serums
Moisturizer
Sun Protections
Night Cream
Lip
Please print name clearly:
I _________________________, do fully understand all the questions above and have answered
them all correctly and honestly. Furthermore, I know that it is my responsibility to alert the
esthetician about any recent surgeries or skin resurfacing procedures. I have had all my questions
addressed and answered to my satisfaction. I take full responsibility for my decision to receive:
___________________________ treatment now and any I may receive in the future. I will not hold
Sundara Day Spa or esthetician liable for any injury or physical condition that may result.
______________________________ ____________________________
Client Signature
Date Signed
Has anything changed since your last visit?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
(If yes please explain)
What? ________________________
What? ________________________
What? ________________________
What? ________________________
What? ________________________
______________________
____________
Client Signature
Date Signed
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Client Signature
Date Signed
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Client Signature
Date Signed
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Client Signature
Date Signed
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Client Signature
Date Signed