Facial Consent Form Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Email * Do you have any experience with facial treatments? * YES NO Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products? * YES NO Have you ever had any laser treatments, chemical peels or microdermabrasion? * YES NO Have you used acne medication? * YES NO Are you receiving any cancer treatments? * YES NO Have you experienced Botox, Restylane, or collagen injections? * YES NO What skin concerns do you currently have? SKIN (CHECK ALL THAT APPLY) Breakouts/acne Sun damage Sun/liver/brown spots Blackheads/whiteheads Redness/ruddiness Wrinkles/fine lines Dull/dry skin Broken capillaries Rosacea Flaky skin Dehydrated skin Uneven skin tone Excessive oil/shine Other What skin concerns do you currently have? EYES (CHECK ALL THAT APPLY) Dehydrated Dark circles Wrinkles Puffiness Other What skin concerns do you currently have? LIPS (CHECK ALL THAT APPLY) Dehydrated Cracked/chapped lips Other Please list any allergies Are you currently pregnant or trying to become pregnant? * YES NO Have you had any recent tanning bed or sun exposure that changed the color of your skin? * YES NO Have you used any hair removal methods in the past 6 weeks? * YES NO May I contact you via email about future promotions and news? * YES NO May I call you at the provided phone number to confirm future appointments? * YES NO * I understand, have read and completed this questionnaire truthfully. I agree tht 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 receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof. Digital Signature * First Name Last Name Date * MM DD YYYY Thank you!