Facial Consent Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Sex *

Male

Female

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Your Skin Type: *

Normal/Combo

Oily

Sensitive

Dry

Mild Acne

Moderate Acne

Mature & Aging

What areas of concern do you have regarding your Skin?

Check all that apply

Breakouts/acne

Uneven skin tone

Blackheads/whiteheads

Sun damage

Excessive oil/shine

Wrinkles/fine lines

Rosacea

Dull/dry skin

Broken capillaries

Flaky skin

Redness

Dehydrated

Sun/liver/brown spots

Other

Have you ever had facials, chemical peels, microdermabrasion, or resurfacing treatments? *

Yes

No

If yes, was it within the last month?

Yes

No

Are you using Retin-A, Retinol, Benzoyl Peroxide, Renova, Tretinoin or Vitamin A? *

Yes

No

Have you ever had an allergic reaction to any of the following?

Check all that apply

Nuts

Soy

Gluten

Dairy

Foods/Fruits

Cosmetics

Medication

Iodine (Shellfish)

Latex

Pollen

Animals

Fragrance

Alpha Hydroxy Acids

Sunscreens

Pollen

Do you take Accutane, Birth Control, or Antibiotics? *

Yes

No

Do you have any of the below health issues?

Cancer

Chemotherapy

Circulatory Issues

High Blood Pressure

Arthritis

Hysterectomy

Hormonal Imbalances

Thyroid

Diabetes

Pregnant

Planning to be pregnant

Lactating

Psoriasis

Recent surgeries

Cold Sores

Eczema

May I call you at the provided phone number to confirm future appointments? *

Yes

No

May I contact you via mail/email about future promotions and news? *

Yes

No

I grant to Jane Esthetics Skincare Spa the right to take photographs and/or videos of me immediately prior to, during, and/or after my treatment. I authorize Jane Esthetics Skincare to copyright, use and publish the same in print and/or electronically. I agree that Jane Esthetics Skincare Spa and affiliates may use such photographs and/or videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. *

Yes

No

Client Signature *

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 disclosures. 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 this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

First Name

Last Name

Date *

MM

DD

YYYY