LASH & BROW ENHANCEMENT

LASH & BROW ENHANCEMENT

FACIAL CONSENT & PROCEDURE

FACIAL CONSENT FORM

1.) First Name *

2.) Last Name *

3.) Phone *

4.) Email *

5.) Date of Birth *

6.) Address *

7.) City *

8.) Postal Code/Zip Code

9.) State *

10.) Within the last year, have you been under a dermatologist's care? Yes No If yes, please specify:

11.) Have you had any health problems in the past year?

Yes

No

12.) List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly?

13.) Do you smoke?

Yes

No

14.) Do you exercise regularly?

Yes

No

15.) Do you follow a restricted diet?

Yes

No

16.) Do you wear contact lenses?

Yes

No

17.) Do you have metal implants, a pacemaker or body piercings?

Yes

No

18.) Rate your level of stress on a scale of 1 to 5 (I= low stress, 5 = high stress)

1
2
3
4
5
No elements found. Consider changing the search query.
List is empty.

19.) Do you have any allergies? Latex, Nickel, etc.?

Yes

No

20.) Do you ever experience these conditions on your skin? Flakiness, Tightness, Obvious Dryness

Yes

No

21.) What SPF sunscreen do you use on your face?

22.) What SPF sunscreen do you use on your body?

23.) Do you burn easily in moderate sunlight?

Yes

No

24.) Have you had any direct sun exposure within the last 48 hours?

Yes

No

25.) Do you have a tendency to redness?

Yes

No

26.) Do you suffer from sinus problems?

Yes

No

27.) Are you prone to cold sores or fever blisters?

Yes

No

28.) Are you currently experiencing a break out?

Yes

No

29.) Do you ever experience burning, itching, or stinging sensations on your skin? If yes please specify:

Female Clients Only

30.) Are you taking oral contraception (birth control)?

Yes

No

31.) Are you pregnant or trying to become pregnant?

Yes

No

32.) Are you lactating?

Yes

No

33.) Are you currently having or due for your menstrual period?

Yes

No

Male Clients Only

34.) Do you have any shaving challenges? If yes please specify.

Questions To Discuss Every Visit

35.) Have you started any new medications since your last visit? If yes, please specify.

36.) What are your expectations with this treatment and today's visit.

CONSENT AND SIGNATURE:

I confirm that (to the best of my knowledge) that the answers I have provided are correct and that I have not withheld

any information that may be relevant to my treatment.

CLIENT CONSENT (OVER 18 YRS OF AGE):

37.) Client Signature

38.) Client Signature Date

PARENT/GUARDIAN CONSENT (UNDER 18 YRS OF AGE):

39.) Parent/Guardian Signature

LASH & BROW ENHANCEMENT

FACIAL CONSENT

& PROCEDURE

FACIAL CONSENT FORM

1.) First Name *

2.) Last Name *

3.) Phone *

4.) Email *

5.) Date of Birth *

6.) Address *

7.) City *

8.) Postal Code/Zip Code

9.) State *

10.) Within the last year, have you been under a dermatologist's care? Yes No If yes, please specify:

11.) Have you had any health problems in the past year?

Yes

No

12.) List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly?

13.) Do you smoke?

Yes

No

14.) Do you exercise regularly?

Yes

No

15.) Do you follow a restricted diet?

Yes

No

16.) Do you wear contact lenses?

Yes

No

17.) Do you have metal implants, a pacemaker or body piercings?

Yes

No

18.) Rate your level of stress on a scale of 1 to 5 (I= low stress, 5 = high stress)

1
2
3
4
5
No elements found. Consider changing the search query.
List is empty.

19.) Do you have any allergies? Latex, Nickel, etc.?

Yes

No

20.) Do you ever experience these conditions on your skin? Flakiness, Tightness, Obvious Dryness

Yes

No

21.) What SPF sunscreen do you use on your face?

22.) What SPF sunscreen do you use on your body?

23.) Do you burn easily in moderate sunlight?

Yes

No

24.) Have you had any direct sun exposure within the last 48 hours?

Yes

No

25.) Do you have a tendency to redness?

Yes

No

26.) Do you suffer from sinus problems?

Yes

No

27.) Are you prone to cold sores or fever blisters?

Yes

No

28.) Are you currently experiencing a break out?

Yes

No

29.) Do you ever experience burning, itching, or stinging sensations on your skin? If yes please specify:

Female Clients Only

30.) Are you taking oral contraception (birth control)?

Yes

No

31.) Are you pregnant or trying to become pregnant?

Yes

No

32.) Are you lactating?

Yes

No

33.) Are you currently having or due for your menstrual period?

Yes

No

Male Clients Only

34.) Do you have any shaving challenges? If yes please specify.

Questions To Discuss Every Visit

35.) Have you started any new medications since your last visit? If yes, please specify.

36.) What are your expectations with this treatment and today's visit.

CONSENT AND SIGNATURE:

I confirm that (to the best of my knowledge) that the answers I have provided are correct and that I have not withheld

any information that may be relevant to my treatment.

CLIENT CONSENT (OVER 18 YRS OF AGE):

37.) Client Signature

38.) Client Signature Date

PARENT/GUARDIAN CONSENT (UNDER 18 YRS OF AGE):

39.) Parent/Guardian Signature

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