Oncology Facial Consent Form Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Email * Type of cancer and date diagnosed * If you are currently undergoing chemotherapy, please list the date you started, the type of chemo and any drugs/medications you are taking * Please list any skin issues you may be experiencing: * Please explain any scalp or hair issues you may be experiencing * Please explain any nail issues you may be experiencing * Please list any other medications or supplements you may be taking (including vitamins, aspirin etc): * Anti coagulants? * Yes No Steroids? * Yes No Skin discoloration? * Yes No Please list any known allergies: * Has cancer or cancer treatments affected any function in your body? * * 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!