Facial Consent and Questionnaire
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Email *
Name *
First & Last
Date of Birth *
MM
/
DD
/
YYYY
Cell phone number *
Do you have any special areas of concern?
Which conditions would you like to improve? *
Check all that apply
Required
Have you had facials in the past? *
If so, how long ago and what was your experience like?
How would you describe your skin? *
Required
How would you rate your skin tolerance to sun exposure? *
Do you experience any of the following? *
Required
What is your current skin care regimen? *
Please select all that you use on a regular basis.
Required
Have you ever had any reactions to chemicals, oils, or other caustic/active substances that caused skin irritation? *
If you selected yes, please explain in the 'other' section below.
Do you blush easily? *
If you selected yes, what are your contributing factors? ie emotions, foods, alcohol, temperature changes, other (please list below)
Do you sunbathe or use a tanning bed? If so, how often? *
Have you had any of the following: peels, microdermabrasion, microneedling, facial surgery, cosmetic surgery, botox, filler, laser resurfacing, IPL?
If you have had any of the above listed treatments (or other treatments you think we should know about) please list them below and when you last had that treatment.
Are you currently being treated for any skin conditions?
If yes, please explain.
How does your skin typically heal? *
Are you prone to cold sores/ blisters?
Clear selection
Have you ever used any of the following...
If yes, please state when in the "other" section
How would you describe your overall health?
Clear selection
Have you had any of the following, past or present? If yes, please describe in the "other" section at the bottom of the list.
Have you ever had a reaction to any of the following...
WOMEN: please check any that apply.
MEN: please check all that apply.
What is your stress level?
Clear selection
Do you normally sleep well?
Clear selection
Do you follow any special diet?
If yes, what is it?
Clear selection
How many ounces of water do you consume daily?
How many cups or caffeine-type drinks do you consume daily?
Coffee, tea, soft drinks, energy drinks
In our treatment session, it may be necessary to recommend alterations or additions to your home care regimen: would that be okay with you?
Your esthetician will recommend the appropriate schedule for future facial treatments in order to achieve your skin improvement goals.
Clear selection
I consent to the taking of photographs to be posted on social media and/or the website.  *
By typing my name below I declare that I do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the esthetician will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my esthetician immediately.   I release and hold harmless the esthetician, Maggie Guy at Naked Aesthetics, harmless from any liability for adverse reactions that may result from this treatment.   I have read and understand all of the foregoing information. *
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