Facials | Beauty Esthetics By Diana Sanchez

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Facial Treatment

First Name *

Last Name *

Date of birth *

Age *

Gender *

Address *

City *

State *

Zip Code *

Phone *

Email *

Emergency contact *

Relationship with the Emergency Contact. *

Phone *

How did you hear about Beauty Esthetics? *

MEDICAL HISTORY

Do you have or have you had any of the following conditions? If yes, please select them:AcneHeart conditionSeborrheaImmune disordersHepatitisLupusAsthmaHerpesPacemakerArthritisHirsutismPhotosensitivityAutoimmune DiseaseHIV/AIDSPolycystic OvariesBlood disorderHypo/Hyper PigmentationPoor Blood CirculationsCancerHysterectomyVaricose VeinsBreathing Problems/ DiseaseInsomniaPsoriasisFever blistersIrregular PeriodsShinglesDiabetesLow/ High Blood PressureThyroid ImbalanceEczema/RashesMenopauseVitiligoEpilepsyMetal bone pins/platesWarts

Please indicate Yes or No to the following questions:

Are you currently (or possibly pregnant)? *YESNO

Do you wear contact lenses? *YESNO

What type of work do you do? *

Do you have any allergies or intolerances such as: (dairy, citrus, aloe vera, chamomile, grapes, essential oils, latex, ginger or any other)? *YESNO

If yes, please specify: *

Are you currently under the care of a doctor? *YESNO

If yes, please specify: *

Have you taken any anticoagulants (such as warfin) or antiplatelet medications (such as aspirin) in the past 6 months? *YESNO

If yes, please specify (includes dates of medication/treatments): *

You smoke? *YESNO

Are you prone to fever blisters or herpes? *YESNO

If yes, please specify: *

Have you had any direct exposure to the sun or tanning beds in the last 6 weeks? *YESNO

If yes, please specify: *

What is your sun exposure like? *NeverLittleModerateExcessive

Have you ever had any cosmetic/plastic surgery? *YESNO

If yes, please specify (include dates of medication/treatments): *

Have you ever had a glycolic acid peel, chemical peel, microdermabrasion, or laser resurfacing? *YESNO

If yes, please specify (include date of your most recent treatment): *

Have you ever received Botox or Collagen injections? *YESNO

If yes, please specify (include date of your most recent treatment): *

Have you ever had a facial before? *YESNO

If yes, please specify: *

Do you use any of these medications (Tretinoin, Retinol, Renova, Tazorac, Differin, Accutane)? *YESNO

If yes, please specify: *

Medical Consent *

I agree that all of the above medical information is true and complete. I agree with the privacy policy and general conditions.

CONSENT FOR FACIAL TREATMENTS

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, 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 read and understand the post-treatment home care instructions.

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, whose signature appears below, 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 hereby authorize BEAUTY AESTHETICS to perform the procedure. I know very well that there are NO refunds and that if for any reason I cannot keep the appointment, I must cancel it 24 hours in advance.

Consent form for Aesthetic treatment

Initial to acknowledge that you have been informed of the following:

I __ in connection with the services and products that would be offered to me hereby give my consent to BEAUTY ESTHETICS who will be THE PROFESSIONAL in my care; confirm the following: *

1- __ I release from all causes and claims that may occur before THE PROFESSIONAL, as a consequence of the services rendered, the products, materials and equipment used in any area of my face or body. *

2- _ I affirm that I have told the truth about my medical history and assume all responsibility for any inconvenience in the application of the procedure or product used by THE PROFESSIONAL. *

3- __ I affirm that I am of legal age, or that in the case of being a minor I give my parents' consent, and that I have read and accepted all the above implications, and sign of my own free will. *

4- __ I understand that the outcome of my personal care is directly related to the condition of my skin or body. *

5- __ The products to be used by the professional will be applied to me with the intention of improving the condition of my body and face, and I allow these products to be used on me. Treatments such as, among others: glycolic acid peels, salicylic acid peels, lactic acid peels, acne treatment, microdermabrasion. *

– I hereby authorize BEAUTY ESTHETICS to perform the procedure. I am well aware that there are NO refunds and that, if for any reason I am unable to attend the appointment, I must cancel the appointment 24 hours in advance.
I understand that, if I do not cancel 24 hours in advance, the session will be counted as attendance, which is deducted from my session package.
✔ I have read, understand and fully accept the recommendations made by the practitioner.

PHOTOGRAPH AND VIDEO RELEASE FORM

I would like your permission to use these photos for advertising. For example: portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate.

With your signature if you would like your photos used or not used in advertising. We also like to tag our clients in photos used on our Instagram profile!

Please indicate if you’d like to allow this or not below:

May we use the Audio Visual content of your session? *

Can we tag you on Instagram? *