The Facial Consent form is a crucial document that ensures clients understand the procedures and potential risks associated with facial treatments. By signing this form, individuals acknowledge their consent and help professionals maintain a safe and informed environment. Ready to take the next step? Fill out the form by clicking the button below.
In the world of skincare and beauty treatments, understanding the importance of a Facial Consent form is essential for both clients and practitioners. This document serves as a vital tool in ensuring that individuals are fully informed about the procedures they are about to undergo. It typically outlines the specific treatments being performed, potential risks and benefits, and any necessary pre- or post-care instructions. By signing this form, clients acknowledge their understanding of the procedure and consent to the treatment, which helps protect both parties legally. Additionally, the form often includes sections for medical history, allergies, and any contraindications that may affect the treatment's safety and efficacy. Overall, the Facial Consent form plays a crucial role in fostering trust and transparency in the client-practitioner relationship, ensuring that everyone is on the same page before any procedure begins.
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Filling out and using the Facial Consent form is an important step for both clients and service providers. Here are some key takeaways to keep in mind:
Skincare Treatments – Client Information and Consent
Name
Address
City
State
Zip
Phone
E-mail
How did you hear about us?
Employer ___________________________________________________________________________________________________ Occupation
___________________________________________________________________________________________________________________________________________
What would you like to achieve from your skin treatment today? ______________________________________________________________________________________________________________________________________________________________
Skin Care History
Have you ever had a facial treatment or chemical peel before? __________ Yes __________ No
Which of the following most closely describes your skin type?
I
Creamy Complexion
Always burns easily, never tans
II
Light Complexion
Always burns, may tan slightly
III
Light / Matte Complexion
Burns moderately, tans gradually
IV
Matte Complexion
Seldom burns, always tans well
V
Brown Complexion
Rarely burns, deep tan
VI
Black Complexion
Never burns, deeply pigmented
Do you have any special skin problems or concerns? ______________________________________________________________________________________________________________________________________________________________________________________
Do you use Retin-A, Renova, or Retinol/vitamin A derivative products? __________ Yes __________ No
Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours? __________ Yes __________ No
Are you currently taking Accutane or have you taken it in the past? _________ Yes __________ No How long ago? _____________________________________________
Have you used other acne medication? __________ Yes __________ No If yes, which one? ________________________________________________________________________________________________________________________________________
Are you exposed to the sun on a daily basis or do you use a tanning bed? __________ Yes __________ No
What skin care products are you currently using? Please list the brand if known:
Cleanser _____________________________________________________________________________
Toner ____________________________________________________________________________________
Mask ___________________________________________________________________________________
Moisturizer _________________________________________________________________________
Eye Product _______________________________________________________________________
SPF _________________________________________________________________________________________
Exfoliation / Scrubs __________________________________________________________
Night Cream _______________________________________________________________________
Treatment / Acne product ____________________________________________
Makeup Brand ___________________________________________________________________
Please circle any areas of concern you have regarding your skin:
Breakouts / Acne
Blackheads / Whiteheads
Excessive Oil / Shine
Rosacea
Broken Capillaries
Redness / Ruddiness
Sun spot / Brown spots
Uneven Skin Tone
Sun Damage
Wrinkles / Fine Lines
Dull / Dry Skin
Flaky Skin
Dehydrated Skin
Sensitive Skin
Eyes:
Dark Circles
Puffiness
Fine lines
Please circle if you have ever had an allergic reaction to any of the following:
Cosmetics
Medicine
Food
Animals
Sunscreens
Pollen
AHAs
Fragrance
Shellfish
Latex
Collagen
Other: ___________________________________________________________________________________________________
Have you ever had Botox, Restylane, or other injections? ______________________________________________________________________________________________________________________________________________________________________________
Ladies only:
Are you taking hormonal contraceptives? __________ Yes __________ No
Are you pregnant or trying to become pregnant? __________ Yes __________ No Are you nursing? __________ Yes __________ No
Experiencing any menopause problems? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Are you undergoing any hormone replacement therapy or cancer treatments? ____________________________________________________________________________________________________________________________________
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. The skin care treatments I receive at Belle Waxing and Skincare are voluntary and I release Belle Waxing and Skincare from liability and assume full responsibility thereof.
Signature
Date