Facial Consent Form

Information you will need

• What's your date of birth?
• What's your mailing address?
• What's your phone number?
• What's your email address?
• CLIENT ONLY: What's your name?
• Is this your first facial treatment?
• Are you being treated for a skin condition?
• What areas concern you?
• Are you pregnant?
• Are you taking birth control?
• What type of birth control do you take?
• Are you taking hormone replacement medication?
• Do you wear contact lenses?
• Do you often experience stress?
• Have you been diagnosed with skin cancer?
• Do you have allergies?
• What type of hormone replacement medication do you take?
• What allergies do you have?
• Have you ever used Accutane?
• How long did you use Accutane?
• Do you have acne?
• How long have you had acne?
• Do you experience frequent blemishes?
• Do you experience oily shine?

…and 33 more fields in the PDF.

Completed by the client.

The form includes 2 signature lines.