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Esthetician

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Name

Date of Birth

Address

City

State

Zip

Phone

Referred Information

Referred By

Phone

Emergency Contact

Occupation

Age

Gender

Male Female

Physician

Health Insurance Carrier

Please take a moment to answer the following questions

Is this your first facial?

Yes No

What is your main concern with your skin?

Are you presently under a physician's care for any current skin condition or other problem?

Yes No

Are you pregnant

Yes No

If Yes, what type?

Are you presently using (or used in the past) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids?

Yes No

If "Yes", when and for how long?

Are you now using or have you ever used Accutane?

Yes No

Are you presently taking any medications?

Yes No

If so, please list

Do you wear contact lenses?

Yes No

Do you smoke?

Yes No

Do you have any allergies to cosmetics, food or drugs?

Yes No

If so, please list

Have you had skin cancer?

Yes No

If so, what?

Do you often experience stress?

Yes No

What skin care products do you use presently?

Affected

Please check if you are affected by or have any of the following

Asthma Cardiac Problems Depression Herpes Fever Blisters Headaches-Chronic Anxiety Epilepsy Hysterectomy Skin Disease Hepatitis High Blood Pressure Sinus Problems Immune Disorders Lupus Pace Maker Eczema Metal Bone Pins or Plates

Please explain above problems or list any other significant issues

I understand that the services offered are not a substitute for medical care; and any information provided by the esthetician, is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential.

The esthetician services I will receive are intended to improve the appearance and health of my skin.

I have disclosed all relevant health information, and I understand that withholding information may increase risks associated with the treatments.

I consent to the esthetic services checked above and understand the procedures involved, including potential risks such as redness, swelling, or allergic reactions.

I agree to follow all post-treatment care instructions provided by my esthetician to ensure optimal results and minimize risks.

Client Signature

Date

Parent/Guardian Signature (if applicable)

Date

Consent to Treatment of Minor: By signature below, I hereby authorize (Parent Name)

Post-Service Care Instructions

Hydrate

Drink plenty of water to help your skin recover.

Avoid Sun Exposure

Stay out of direct sunlight and use sunscreen as directed.

Do Not Pick or Scratch

Avoid touching the treated area to prevent irritation or infection.

Follow Skincare Regimen

Use any recommended products or treatments as directed.

Monitor Your Skin

Watch for any unusual reactions (e.g., excessive redness, swelling) and contact your esthetician or healthcare provider if necessary.

Contact Us

By Appointment Only
Service 7 Days A Week
Morning Day Evening Hours

Payments Accepted

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Insurance
Gift Card