Consent for Facial Treatment
PLEASE PRINT LEGIBLY
All INfOIMAflOH Wltl IE ICE,1 CONfl DENTl.Al
Name:
Phone: Home
Address:
E-mail:
Work
Cell
_
City/State/Zip:-----------Oate of B
irth:__, . Occupat ion:
_
Emergency Contact:
Relationship:
Referred by: olnternet oSpaFinder oSpaWish oOirect Mail oOther:
Would you like to receive occasional e·mail promotions?
Yes
Phone:-------
ONo
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 know1edge.
Have you ever had a facial treatment before? OYes ONo Date of last facial: ------------­
Are you currently under a physician's care for any skin condition? OYes :)No If yes, please explain: ----How many ounces of water do you drink per day? ------------------------­
Check all that apply.
O Baci</Neck Problems
O Headaches/Migraines
O Skin Infections/Disorders
o Sinus Problems
O Cancer History
O TMJ Dysfunction.Jaw Pain
o Stroke History
O High or ow Blood Pressure:
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? OYes ONo If yes.please list: --------------Female Clients Only:
Are you takingoral contraceptives?
JYes
0No If yes.pleaselist: ----------------­
Any recent changes to or from your contraceptive treatment? JYes
JNo If yes, what and when: -----Are you undergoing any hormone replacement therapy?
)Yes
JNo
If yes.please specify: --------
CURRENT ANO PAST SKINCARE TREATMENTS/SE.RVICES
Check all that apply.
V Accutana
o Facial Waxing
0FacialCosmetic Surgery
O Microdermabrasion
O Chemical Peels/Pholofacials
o lnjectables/Derrnal Fillers
O aser TreatmenlS
o Oralflopical
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:
O Tendency towards redness
O Skin breakouts
O Sun Damage
o Sunb<Jrnlblush easily
o Oily duringday
o Dry Skin
Aging skin·fine lineslwrinkles
SELECT ALL PAST REACTIONS/ALLERGIES THAT APPLY AND EXPLAIN
'.:> Cosmetics:
o Enzymes:
_
_
O Foods:
.:> Fragrance:
_
'.:> Glycolicllactic Acid : ------------------------------­
'> Iodine:
O Medicine: ----------------------------------0 Sa
licytic Acid: --------------------------------o
sunsoreens :---------------------------------If any condition that you have mal1<ed above needs to be detailed or if there is anything else to share, please do so: