Unique Skincare Boutique Consent Form

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Questionnaire and Consent Form. Please submit prior to your appointment.

*** Please note it is your responsibility to notify me prior to your appointment if any of your medications, medical conditions, or allergies change.

Date: *

YYYY

Name: *

Email Address: *

Cell Phone: *

Occupation *

Referred by: *

Date of birth: *

YYYY

Do you smoke: *

Yes

Other:

Under Doctor's or Dentists care in the last 8 weeks? If yes, for what? *

Medications/Supplements that you have taken in the last 8 weeks including but not limited to birth control or cosmetic injections. Also please include any and all topical medications. *

Pregnant or nursing? *

Yes

Maybe

Diabetes 1 or 2/Gestational? *

yes

Do you have any Allergies? If yes, please list all. *

Current Skincare Products used? Please list any rx as well.

Do you wear sunblock? *

Yes

infrequently

Other:

Do you get cold sores or herpes lesions? *Please note if you currently having an outbreak I will need to reschedule you. *

Yes

Maybe

Have you ever previously had a staph or MRSA infection? Or any other skin or blood born communicable infections? *

Yes

Maybe

Will you be travelling or tanning in the next two weeks? If so, when? *

Have you used accutane in the last two years? *

Yes

Maybe

Do you use Prescription or non-prescription retinols (tretinoin) or AHA's? If yes, how often and what? *

For Skincare clients; Is there anything you would like to improve upon with your skin?

For Skincare clients: What do you perceive to be your skin type? Dry, combo, sensitive, or oily?

For Skincare clients: What are your goals for this treatment or subsequent treatments. (I.e. relax or brighten skin or even skin tone? Etc.)

Read Completely: Waiver/Consent to treat by Bri Nejad.

I hereby consent to and authorize, Bri Nejad, to perform the following procedure(s):Facials/ Microdermabrasion/ Facial Peels/ Dermaplaning/Hydrodermabrasion/ Microdermabrasion/ makeup services/ Waxing/ and/or Eyelash tinting/treatments, I have voluntarily elected to undergo this treatment/procedure. Waxing and/or any or all Skincare services listed above may cause bruising, scabs, scarring, redness, hyperpigmentation, pimples or histamine reactions. Although it is impossible to list every potential risk and complication, I have asked, Bri Nejad, about possible benefits, risks, and complications that I am concerned about. I accept all risks and consent to treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, adherence to home care, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have asked and understand the post-treatment home care instructions for the service or services I will or have received. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, Bri Nejad, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I also agree to voluntarily update Bri Nejad, of any new information regarding my health or skincare products PRIOR to any future appointments.

Date *

YYYY

Client Name: *

Electronic Signature: *

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