Facial Consent Form

FACIAL TREATMENT INTAKE FORM
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Facials are customized to your skin needs and goals. Please be sure to list all possible skin conditions and medications to be sure the right products are chosen for you. For any concerns please reach out to me directly!

Must be 18 or have parent guardian consent. Parent does not need to remain at appointment but must be with client upon arrival for confirmation of consent.
YesNo
If no, a parent/guardian must consent to treatment. Please print the name of parent/guardian below:
YesNo
YesNo
If yes, please list medications below
YesNo
YesNo
If yes, please list below:
CancerCardiac problemsDiabetesEpilepsyCold SoresHigh Blood PressureImmune DisordersDigestive ImbalancesSinus Pressure/HeadachesNone
YesNo
YesNo
YesNo
YesNo
NormalCombinationDryOilySensitiveBreakout ProneDull
Acne/BreakoutsDry/Flaky skin or patchesSun DamageAging SkinLarge PoresFine Lines/WrinklesUneven Tone/TextureRedness/RosaceaUnder-eye Darkness/CirclesUnder-eye Lines/WrinklesUnder-eye Puffiness
AspirinAlpha Hydroxy AcidsNutsLatexShellfishNone
Please list ANY ingredient allergies you may have:
Mind/Body Health
Anxiety/StressLow energyHeadaches/MigrainesMuscle aches/painsInsomnia/Difficulty sleepingLow immunity (Sick often)Mental exhaustion
Please list additional concerns or conditions below:
YesNo
Date*

MonthDayYear
Date
By signing/dating below, confirm that the information given is accurate before proceeding with the service (For those under 18 years of age please have parent/guardian sign below):

Clear
Printed name*
Should be Empty:

FACIAL TREATMENT INTAKE FORM

Mind/Body Health