Evolve Skin Care Facial & Services Consent Form
THIS FORM MUST BE COMPLETED AND SIGNED BEFORE RECEIVING A FACIAL
Medical Information Circle one of the following:
1. Is your skin more: Normal/Oily Normal/Dry Oily Dry Sensitive
2. What is your concern with your skin TODAY?
o Fine Lines/ Aging
o Darkness/Discoloration
o Acne/Congestion/ Breakouts
o Dry/Flakey
o Maintain healthy looking skin
Other/Explain:_______________________________________________________________________________________________________________________________________________________________
3. Are you currently taking any medications or supplements?
__________________________________________________________________________________
4. Do you have any allergies? If yes, list below:
_________________________________________________________________________________
5. What skin care products are you currently using?
____________________________________________________________________________________________________________________________________________________________________
6. Do you use Retin A, Renova, or Accutane? Have you recently received chemical peels, lasers, microdermabrasion? __________________________________________________________________________________
7. Have you recently had any surgeries, broken bones, or illnesses?
__________________________________________________________________________________
8. Do you experience breakouts? Yes No
If yes, Where?______________________________________________________________________
9. Are there any chances that you may be pregnant? Yes No
10. Are you currently menstruating?
11. What are your skin care goals? __________________________________________________________________________________
12. What was your favorite part of your last facial or massage?_________________________________________________________________________
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.
Who can we thank for referring you or how did you hear about us? _______________________________________
Print Name:_________________________________________Phone:________________________________
Signature:_______________________________________Date:____________________________________ E-Mail:______________________________________________________________________