Facial Treatment Consultation and Consent Form 1.Client Information Full Name Date of Birth Address Phone Number Email Emergency Contact Name Emergency Contact Phone Number Relationship to Emergency Contact 2.Medical History Skin Health Do you have or have you ever had any of the following skin conditions? (Please tick all that apply) Acne Eczema Psoriasis Rosacea Dermatitis Keloid Scarring Hyperpigmentation Hypopigmentation Skin Cancer Other (Please specify) Medical Conditions Do you have any of the following medical conditions? (Please tick all that apply) Diabetes Heart Disease High/Low Blood Pressure Autoimmune Disorders Epilepsy Blood Clotting Disorders Thyroid Conditions Hepatitis (A, B, C) HIV/AIDS Asthma Allergies (Please specify): Allergies (Please specify): Medications and Treatments Are you currently taking any medications (oral or topical)? (Include prescriptions, over-the-counter drugs, vitamins, and supplements) Yes No If yes, please list: Have you recently used any of the following? Retin-A, Renova, or other retinoid products Accutane or other isotretinoin products Alpha Hydroxy Acids (AHAs) or Beta Hydroxy Acids (BHAs) Steroids or anticoagulants Photosensitizing medications Lifestyle Factors Do you smoke tobacco or use nicotine products? Yes No Do you consume alcohol? Yes No If yes, how often? Are you pregnant or breastfeeding? Yes No N/A Do you have any metal implants or a pacemaker? Yes No Previous Treatments Have you had any of the following treatments in the past 6 months? (Please tick all that apply) Facials Chemical Peels Microdermabrasion Laser Treatments Botox or Dermal Fillers Cosmetic Surgery Other (Please specify): 3.Skin Care Routine What skincare products are you currently using? (Brands and product names) Cleanser Toner Moisturizer Sunscreen Exfoliants Treatments/Serums 4. Treatment Goals What are your primary skin concerns? (Please tick all that apply) Fine Lines and Wrinkles Acne or Breakouts Dryness or Dehydration Oily Skin Uneven Skin Tone Hyperpigmentation Sensitivity Enlarged Pores Other (Please specify): 5. Consent and Acknowledgement Treatment Information I acknowledge that I have been informed about the facial treatment, including: *The nature and purpose of the treatment. *The potential benefits and expected outcomes. *Possible risks, side effects, and complications. *Pre-treatment and post-treatment care instructions. Photography Consent (Optional) Yes, I consent to photographs being taken before and after my treatment for: My client record Marketing and promotional purposes (identity will be kept confidential) No, I do not consent to photographs being taken. 9. Client Signature By signing below, I acknowledge that I have read and understood all the information in this consultation and consent form. I agree to the terms herein and consent to receive the facial treatment. Send