Contents
Form Preview Example
Skincare Treatments – Client Information and Consent
Name
Address
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Phone |
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How did you hear about us? |
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Employer ___________________________________________________________________________________________________ Occupation |
___________________________________________________________________________________________________________________________________________ |
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What would you like to achieve from your skin treatment today? ______________________________________________________________________________________________________________________________________________________________
Skin Care History
Have you ever had a facial treatment or chemical peel before? __________ Yes __________ No
Which of the following most closely describes your skin type?
I |
Creamy Complexion |
Always burns easily, never tans |
II |
Light Complexion |
Always burns, may tan slightly |
III |
Light / Matte Complexion |
Burns moderately, tans gradually |
IV |
Matte Complexion |
Seldom burns, always tans well |
V |
Brown Complexion |
Rarely burns, deep tan |
VI |
Black Complexion |
Never burns, deeply pigmented |
Do you have any special skin problems or concerns? ______________________________________________________________________________________________________________________________________________________________________________________
Do you use
Have you used any
Are you currently taking Accutane or have you taken it in the past? _________ Yes __________ No How long ago? _____________________________________________
Have you used other acne medication? __________ Yes __________ No If yes, which one? ________________________________________________________________________________________________________________________________________
Are you exposed to the sun on a daily basis or do you use a tanning bed? __________ Yes __________ No
What skin care products are you currently using? Please list the brand if known:
Cleanser _____________________________________________________________________________ |
Toner ____________________________________________________________________________________ |
Mask ___________________________________________________________________________________ |
Moisturizer _________________________________________________________________________ |
Eye Product _______________________________________________________________________ |
SPF _________________________________________________________________________________________ |
Exfoliation / Scrubs __________________________________________________________ |
Night Cream _______________________________________________________________________ |
Treatment / Acne product ____________________________________________ |
Makeup Brand ___________________________________________________________________ |
Please circle any areas of concern you have regarding your skin: |
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Breakouts / Acne |
Blackheads / Whiteheads |
Excessive Oil / Shine |
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Rosacea |
Broken Capillaries |
Redness / Ruddiness |
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Sun spot / Brown spots |
Uneven Skin Tone |
Sun Damage |
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Wrinkles / Fine Lines |
Dull / Dry Skin |
Flaky Skin |
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Dehydrated Skin |
Sensitive Skin |
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Eyes: |
Dark Circles |
Puffiness |
Fine lines |
Please circle if you have ever had an allergic reaction to any of the following: |
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Cosmetics |
Medicine |
Food |
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Animals |
Sunscreens |
Pollen |
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AHAs |
Fragrance |
Shellfish |
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Latex |
Collagen |
Other: ___________________________________________________________________________________________________ |
Have you ever had Botox, Restylane, or other injections? ______________________________________________________________________________________________________________________________________________________________________________
Ladies only:
Are you taking hormonal contraceptives? __________ Yes __________ No
Are you pregnant or trying to become pregnant? __________ Yes __________ No Are you nursing? __________ Yes __________ No
Experiencing any menopause problems? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Are you undergoing any hormone replacement therapy or cancer treatments? ____________________________________________________________________________________________________________________________________
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. The skin care treatments I receive at Belle Waxing and Skincare are voluntary and I release Belle Waxing and Skincare from liability and assume full responsibility thereof.
Signature |
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Date |
Common mistakes
Filling out a Facial Consent form is an important step in ensuring a safe and effective treatment. However, many people make mistakes that can lead to misunderstandings or complications. One common error is failing to read the form thoroughly. Many individuals rush through the process, missing crucial information about the procedure, potential risks, and aftercare instructions. Taking the time to read each section can prevent future issues.
Another frequent mistake involves incomplete information. When clients do not provide all requested details, it can hinder the practitioner’s ability to assess their suitability for the treatment. Missing medical history or allergies may lead to adverse reactions. It is essential to fill out every section accurately and completely to ensure safety.
Some individuals neglect to ask questions about the form or the procedure itself. If anything is unclear, it's vital to seek clarification from the practitioner. This lack of communication can result in confusion about what to expect during and after the treatment. Remember, your understanding is key to a positive experience.
Additionally, people sometimes overlook the importance of signing and dating the form. A signature is not just a formality; it signifies that you understand and agree to the terms outlined. An unsigned form may not be valid, which could complicate your treatment. Always double-check that all necessary signatures are present.
Lastly, many forget to keep a copy of the completed form for their records. Having your own copy can be beneficial for future treatments or consultations. It serves as a reference point for any questions or concerns that may arise later. Always ask for a copy after submission to ensure you are fully informed.
Dos and Don'ts
When filling out the Facial Consent form, it's important to follow certain guidelines to ensure clarity and accuracy. Here are eight things you should and shouldn't do:
- Do read the entire form carefully before signing.
- Do provide accurate personal information.
- Do ask questions if you do not understand any part of the form.
- Do sign and date the form in the appropriate sections.
- Don't rush through the form; take your time to ensure completeness.
- Don't leave any required fields blank.
- Don't sign the form if you feel pressured or unsure.
- Don't forget to keep a copy for your records.
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Similar forms
The Facial Consent form is an important document in the realm of personal care and medical procedures. It shares similarities with several other documents, each serving a unique purpose while ensuring informed consent and protection for both the provider and the individual. Below are six documents that are similar to the Facial Consent form:
- Medical Consent Form: This document is used in various healthcare settings, allowing patients to authorize medical treatments or procedures after understanding the risks and benefits involved.
- Informed Consent Form: Commonly used in clinical trials and research studies, this form ensures participants are fully aware of the study's nature, potential risks, and their rights before agreeing to take part.
Employment Verification Form: The Florida Employment Verification form is critical for employers to confirm the employment eligibility of their workers. This form, which serves to verify both identity and employment authorization, aligns with federal regulations and offers peace of mind to both parties. For further details, visit TopTemplates.info.
- Release of Liability Waiver: Often used in recreational activities or physical fitness settings, this document protects providers from legal claims by participants who may be injured during the activity.
- Cosmetic Procedure Consent Form: Similar to the Facial Consent form, this document is specifically tailored for cosmetic surgeries or treatments, detailing the procedure, potential complications, and expected outcomes.
- Privacy Notice: This document informs individuals about how their personal information will be used and protected, ensuring compliance with privacy laws and regulations in various settings.
- Emergency Medical Consent Form: In situations where immediate medical attention is required, this form allows healthcare providers to administer treatment when the patient is unable to give consent themselves.
Each of these documents plays a crucial role in ensuring that individuals are informed and protected in various contexts, much like the Facial Consent form does in the realm of facial treatments.