CONSENT SERVICES FORM Treatment Consent Form - [lumbertan]

Consent Treatment Consent Form (lumbertan)

CONSENT SERVICES FORM

Treatment Consent Form

CLIENT INFORMATION FORM

Name

Address

City

State

Zip Code

Country

Birthday

Phone

What skin care products are you currently using?
Please answer to the best of your ability:

BRAND

AM Skin Care Routine

Cleanser

Toner

Exfoliation or Scrub

Serum

Moisturizer

Sunscreen

Eye Cream

Other products or Rx

PM Skin Care Routine

Cleanser

Toner

Exfoliation or Scrub

Serum

Moisturizer

Sunscreen

Eye Cream

Other products or Rx

Are you pregnant, lactating, or plan on becoming pregnant soon?

Yes

List all known allergies (food, products, ingredients, etc.

Have you ever had a reaction to skin care products or ingredients?

Yes

Explain:

Are you using any prescribed exfoliants? (Retin-A, Epiduo, Differin, Renova, Accutane, etc.)

Yes

Explain:

Are you currently taking any medication that could interfere with a facial treatment?

Yes

Explain:

Please select to Indicate Your Acknowledgement

I understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face and provide light exfoliation.

The nature and purpose of Dermaplaning has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure.

I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness, mild irritation, and dryness. Additionally, nicks to the skin can occur due to the sharp surgical blade. If a chemical peel is included with this treatment, I understand that the sensation and penetration of the peel will be enhanced. This may cause skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores, when virus is already present in the body.

Chemical Peel: Please Initial to Indicate Your Acknowledgement

I understand my Esthetician will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions. I understand that, very rarely, permanent damage occurs

I have given an accurate account of any over the counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my Esthetician.

I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

Waxing Consent: Please select to Indicate Your Acknowledgement

I have given an accurate account of any over the counter or prescription medications that may interfere with my waxing service, such as to Accutane, Retin-A, Differin, Renova, blood thinners, high antibiotic use, Retinol and alpha-hydroxy products.

I understand that it is my responsibility to bring up any questionable products that I may be using. I also understand that dry skin or regular skin sensitivity may cause irritation or tearing of the skin during a waxing service

Photo Consent: Please select to Indicate Your Acknowledgement

I hereby grant permission to Fairy lashes Brow Lumbertan to take photos to use for any confidential charting purposes. From time to time, Fairy lashes Brow Lumbertan may use client photographs for marketing on Fairy lashes Brow Lumbertan website, printed marketing, or social media platforms. These photographs are used to represent and promote Fairy lashes Brow Lumbertan treatments, skin care and other services.

YES, I have read and agree to all terms stated above and authorize Fairy lashes Brow Lumbertan to use photographs of myself on Fairy lashes Brow Lumbertan website, printed marketing, or social media platforms.

NO, I do not authorize Fairy lashes Brow Lumbertan to use my photograph.

Consent for Facial Treatment: Please select to Indicate Your Acknowledgement

I understand that redness, sensitivity, peeling or other reactions may occur from a facial treatment. I further understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment.

I understand that facial results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type, condition, degree of sun/environmental damage, pigmentation levels, or acne condition.

I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I certify that I am at least 18 years of age, or I have a parental consent co-signed below.

I certify that I have read the above consent and I fully understand it and give my consent to treatment. The treatments I
receive here are voluntary and I release Fairy Lashes Brow Lumbertan and/or the Esthetician from liability and assume full
responsibility thereof.

Printed Name

Date

Treatment on a Minor: Please select Yes to Indicate Your Acknowledgement

Yes

Treatment on a Minor: Please select to Indicate Your Acknowledgement

I understand and agree to everything above, and in addition: I verify the minor client is of sufficient age and aptitude as to provide verbal feedback to the esthetician before, during and after the treatment.

I understand that I am welcome and encouraged to remain in the treatment area/room during the entire length of the appointment

Printed Name:

Signature:

Sign Here

Parent Name:

Parent Signature

Parent Signature Sign Here

Signature

Sign Here