Esthetician Services Consent Form printable pdf download

Esthetician Services Consent Form

THIS FORM MUST BE COMPLETED & SIGNED BEFORE RECEIVING A FACIAL

General & Medical Information

List any medications, supplements that you are currently taking:

____________________________________________________________________________

What temperature of water do you cleanse with?

____________________________________________________________________________

Do you have any specific skin care problems / allergies pertaining to your face or body?

___________________________________________________________________________

What skin care products do you currently use?

___________________________________________________________________________

Have you ever had chemical peel, laser, microdermabrasion, or any skin resurfacing

treatments?__________ If yes, when was your last treatment? ________________________

Do you use Retin A, Renova, or Adapalene? ______________________________________

Do you use acne medication? _______What kind? _________________________________

Do you burn easily? _______ Do you experience an oily shine during the day? __________

Do you wear SPF? ______ Are you currently having your menstrual period? ____________

Do you experience breakouts? ______ Are you taking oral contraceptives? _____________

What are your skin care goals? ________________________________________________

If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that

the products and/or technique may be adjusted to my level of comfort. I further understand that facial

should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand

that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness,

and that nothing said in the course of the session given should be construed as such. Because certain

treatments should not be performed under certain medical conditions, I affirm that I have stated all my

known medical conditions, and answered all questions honestly. I agree to keep the esthetician updated

as to any changes in my medical profile during the session and understand that there shall be no liability

on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks

or advances made by me will result in immediate termination of the session. I also understand that the

Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom he/she deems to

have a condition for which facial treatments are contraindicated.

Client Signature ________________________________________________ Date _________

NAME: ___________________________________ PHONE: _______________________

EMAIL: ___________________________________ ESTHETICIAN’S NAME: Ellie Wilson

Thank you and Enjoy your Facial!

Esthetician Services Consent Form