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Facial Consent Sample

Skincare Treatments – Client Information and Consent

Name

Address

City

 

 

 

 

State

 

 

Zip

 

 

Phone

 

 

E-mail

 

 

 

 

 

 

How did you hear about us?

 

 

 

 

 

 

 

 

 

 

Employer ___________________________________________________________________________________________________ Occupation

___________________________________________________________________________________________________________________________________________

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 Retin-A, Renova, or Retinol/vitamin A derivative products? __________ Yes __________ No

Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours? __________ Yes __________ No

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:

 

 

Breakouts / Acne

Blackheads / Whiteheads

Excessive Oil / Shine

 

Rosacea

Broken Capillaries

Redness / Ruddiness

 

Sun spot / Brown spots

Uneven Skin Tone

Sun Damage

 

Wrinkles / Fine Lines

Dull / Dry Skin

Flaky Skin

 

Dehydrated Skin

Sensitive Skin

 

Eyes:

Dark Circles

Puffiness

Fine lines

Please circle if you have ever had an allergic reaction to any of the following:

 

 

Cosmetics

Medicine

Food

 

Animals

Sunscreens

Pollen

 

AHAs

Fragrance

Shellfish

 

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

 

Date
⇓ PDF File

Instructions on Utilizing Facial Consent

After obtaining the Facial Consent form, you will need to complete it before your scheduled appointment. This ensures that all necessary information is collected accurately. Follow the steps below to fill out the form correctly.

  1. Begin by writing your full name in the designated field at the top of the form.
  2. Next, provide your contact information, including your phone number and email address.
  3. Fill in your date of birth. Ensure that the format is consistent with the example given on the form.
  4. Indicate any allergies or skin sensitivities you may have in the appropriate section.
  5. Review the list of procedures that may be performed and check all that apply to you.
  6. Sign and date the form at the bottom to indicate your consent.
  7. Make a copy of the completed form for your records, if necessary.

Misconceptions

Many people have misunderstandings about the Facial Consent form. Here are ten common misconceptions, along with clarifications to help you understand its purpose and importance.

  1. It is only a formality. Many believe the consent form is just a bureaucratic step. In reality, it is a crucial document that ensures clients are informed about the procedure and any associated risks.
  2. Signing means I cannot hold anyone accountable. Some think that by signing the form, they waive all rights to seek accountability. This is not true; it simply acknowledges that you understand the risks involved.
  3. All procedures are the same, so one form suffices. Each facial treatment can involve different techniques and risks. Each procedure may require a specific consent form tailored to those particular aspects.
  4. I can skip reading the form. Some individuals feel they can sign without reading. It is essential to read the form thoroughly to understand what you are consenting to.
  5. Consent forms are only for new clients. Existing clients also need to sign updated consent forms, especially if there are changes in procedures or products used.
  6. Once signed, I cannot change my mind. Signing the form does not mean you cannot change your mind about the procedure at any time before it begins.
  7. The form protects only the service provider. While it does provide protection to the provider, it also serves to inform and protect the client by ensuring they are aware of potential risks.
  8. I don’t need to ask questions. Clients are encouraged to ask questions before signing. This helps ensure that you fully understand the treatment and any concerns you may have.
  9. My consent is valid forever. Consent is specific to the treatment and the time it was given. If there are changes in your health or the procedure, a new consent may be necessary.
  10. It is not legally binding. A properly executed consent form is legally binding. It reflects your informed consent and understanding of the treatment.

Understanding these misconceptions can help ensure that you feel confident and informed about your decisions regarding facial treatments. Always take the time to read and comprehend any consent form you are asked to sign.

Documents used along the form

When undergoing facial treatments, various forms and documents are typically required to ensure a smooth process. Each document serves a specific purpose, providing essential information and consent regarding the treatment. Below is a list of commonly used forms that may accompany the Facial Consent form.

  • Patient Information Form: This document collects personal details, including contact information, medical history, and any allergies. It helps the practitioner understand the patient's background and tailor treatments accordingly.
  • Medical History Questionnaire: A more detailed form that asks about past surgeries, medications, and health conditions. This information is crucial for assessing any risks associated with the treatment.
  • Waiver of Liability: This form outlines the risks involved in the treatment and ensures that the patient acknowledges and accepts those risks. It protects the provider from potential legal claims.
  • Aftercare Instructions: This document provides guidance on how to care for the skin post-treatment. It includes recommendations for products to use and activities to avoid to ensure optimal healing.
  • Before and After Photos Consent: Patients may be asked to consent to having their photos taken before and after the treatment. This helps track results and may be used for marketing purposes.
  • Payment Authorization Form: This form outlines the costs associated with the treatment and authorizes the provider to charge the patient's payment method. It ensures transparency in financial transactions.
  • Durable Power of Attorney Form: For those wishing to ensure their affairs are handled according to their wishes, even in times of unexpected incapacity, completing a Durable Power of Attorney form is a critical step.
  • Referral Form: If the treatment requires a referral from another healthcare provider, this document facilitates communication between practitioners. It ensures that all relevant medical information is shared.
  • Appointment Cancellation Policy: This document informs patients about the practice's policy regarding cancellations and no-shows. Understanding these policies helps avoid misunderstandings in scheduling.

Each of these documents plays a vital role in the treatment process. They ensure that both the patient and the provider are on the same page regarding expectations, responsibilities, and care. Proper documentation not only enhances the patient experience but also safeguards the interests of the healthcare provider.