Facial Client Consent

1. Client Information *
2. Have you been under the care of a physician, dermatologist, or other medical professional within the past year?
3. Please list Doctor and ailment:
4. Any recent surgery, including plastic surgery?
5. Please list surgeries:
6. Have you had skin cancer:
7. Have you had any of these health conditions in the past or present (select all that apply)
8. Please list any prescribed or OTC medications you are taking:
9. Are you using any skin products prescribed by a Doctor or Dermatologist?
10. Do you have any metal implants, coils, or wear a pacemaker?
11. Have you had an adverse reaction to any skin care product, ingredient, or procedure? Please explain.
12. Do you suffer from any food allergies?
13. Are you allergic to any of the following:
14. Are you currently pregnant?
15. Can we contact you via text/email with specials and or communication?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.