Facial Consent Form
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Email *
Full Name: *
Address, City, State, Zip Code *
Phone Number: *
Date of Birth: *
MM
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DD
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Occupation:
Emergency Contact: *
Phone Number: *
Do you have any health problems or concerns that I need to be aware of before treatment? If yes, please describe: *
Any recent surgeries on your face, neck, or shoulders? *
Are you currently, or have you ever used Retin-A, Renova, Resorcinol, or any powerful Hydroxyl Acids within the past 3 months? *
Are you currently using or taking Accutane? *
Are you using any other skin thinning products or drugs? *
Are you diabetic? *
Do you use a tanning bed? *
Are you exposed to the sun daily or will you spend more time out in the sun anytime soon? *
Do you currently wear contact lenses? *
Have you experienced Botox, Restylane, or Collagen Injections? *
Please select the following conditions you have/had experienced: *
Required
Please select the following that best describes your skin type: *
Are you under the care of a dermatologist? *
What are your skin concerns, or challanges? *
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosure. 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 the esthetician from liability and assume full responsibility thereof. *
Required
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