Client Form 3 – Facial Services Consent Form

Client Information

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Phone Number(Required)

Email Address(Required)

Previous Facial Experience

Have you ever had a facial before?

Yes

Health & Skin Questionnaire

Please take a moment to carefully read the following information and sign where indicated. If you have a medical condition or specific symptoms, a facial may be contraindicated. A referral from your primary care provider may be required prior to the service being provided. Check YES or NO as it applies. If your answer is “YES” to any of the following questions, please explain as clearly as possible.

1. Have you been under a Dermatologist's care within the last year?(Required)

Yes

2. Within the last 10-12 months, have you undergone any surgeries?(Required)

Yes

3. Do you smoke?(Required)

Yes

4. Do you wear contact lenses?(Required)

Yes

5. Do you have any facial implants and/or piercings?(Required)

Yes

6. Do you have a pacemaker?(Required)

Yes

If you answered YES to any of the above health questions, please explain to the best of your ability in the space below:

Skin Concerns

Please indicate if you have any of the following skin concerns by checking YES or NO:

1. Do you have any special skin problems pertaining to your body or face?(Required)

Yes

2. Do you have issues with acne/breakouts?(Required)

Yes

3. Do you have issues with whiteheads/blackheads?(Required)

Yes

4. Do you have issues with excessive oil/shine?(Required)

Yes

5. Do you have issues with redness/rosacea?(Required)

Yes

6. Do you have issues with uneven skin tone, light spots, or dark spots?(Required)

Yes

7. Do you have issues with sun damage?(Required)

Yes

8. Do you have issues with dull, flaky, or dry skin?(Required)

Yes

Allergies and Skin Care Routine

Do you have any allergies? Please list all allergies in the space below:

What is your main skin goal?

What does your daily skincare regimen look like? What products are you using?

Do you use SPF on your face daily?(Required)

Yes

Are you currently on Accutane?(Required)

Yes

Consent for Services
I understand that I will receive facial services and fully consent to have this service performed. I understand that this consent will remain in effect for this procedure and all future procedures conducted by my Technician/Aesthetician.
I release Jardin Secret Spa/Wellness Center, staff, and specific technicians from liability associated with this procedure. I understand this consent agreement will stand for my appointment today and all other future appointments.

Please type your full name below to consent.

Client's Full Name:(Required)

Today's Date(Required)

MM slash DD slash YYYY

Type your full name as your signature to complete the consent form. If the client is under the age of 18, a parent or guardian can sign on their behalf, giving permission for this service to be performed on their child.

eSignature(Required)