Facial Consent Form

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Birthday *

Date

Have you ever had a facial treatment before? *

Yes No

Have you had facial waxing or threading in the past 72-hours? *

Yes No

Have you taken Accutane in the past 12-months? *

Yes No

In the past year, have you been under the care of a Dermatologist? *

Yes No

Are you currently undergoing Chemo-therapy? *

Yes No

What SPF do you use on your face? *

Do you wear contact lenses? *

Yes No

Have you had Laser Treatments, Chemical Peels, or Microdermabrasion in the past month? *

Yes No

Are you currently using products that contain AHA, Retinol, or Vitamin A? *

Yes No

Allergies: *

Current Medications: *

Have you had Botox or Restylane injections? *

Yes No

Are you currently pregnant or nursing? *

Yes No

My skin concerns are... *

I understand that withholding information or providing false information may result in complications or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Scarlett's Beauty Bar & Spa from liability and assume full responsibility thereof.

Clients under the age of 18 must have a parent or legal guardian present to provide consent for this facial treatment. I agree to communicate with my Service Provider anytime during this treatment if I feel as though my well-being is being compromised. I have given all important information regarding medications and heath to my service provider and will update them if anything changes.

I understand and voluntarily accept the risks associated with the facial or other services provided.

Signature *

Clear

RETURNING CLIENT NOTES - changes in skin care regimen or medications