Facial Concent Form

Facial consent form

Name *

Civil ID *

Age *

- Gender - *

Cell phone *

Address *

How did you hear about us *

Skin care history.
Have you ever had a facial treatment or chemical peel before? *

Yes

Have you ever had a facial treatment or chemical peel before? *

Acne

Dark spots

Clogged proes

Scaring

Sensitive

Dryness

Excessive oiliness

skin laxity

OtherOther

Are you taking birth control pills?
If yes what type? *

YesYes

Are you pregnant ?
If yes How many months are you? *

YesYes

Are you presently using or used in the past, azelx, differin, Retin_A, Clycolic or Alpha hydroxy acid?
If yes, When and for how long? *

YesYes

Please check the products you currently use and their brand names? *

Face wash

Toner

Seurum

Exfolian SPF

Immune Disorders

Eye cream

Moisturizer

OtherOther

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

Heroes

Depression

High blood Pressure

Immune Disorders

Epilepsy

Heart Disease

OtherOther

Please explain above problem or list any other significant issue

In the past 30 days, please list all professional facial or dermatology service you have recived

All of the information is true and accurate to the best of my knowledge I take full of responsibility for allerting my esthetician to any facial or mental condition which would affect by service or results , I understand my treatment is therapeutic in nature and will alert my esthetician to any dis comfort initials

Patient Signature *

Clear

If you are human, leave this field blank.