Facial Consent Form

Full Name*

Date*

Your email*

Date of Birth*

Address*

How did you hear about us?*

Walked By

Online Search

Facebook/Instagram

Referral

If referred, by who?

Are you currently under the care of a physician

Yes

No

Have you experiences any of these health conditions in the past or present?

Hormone Imbalance

High Blood Pressure

Heart Problem

Auto-immune Disorder

Epliepsy/Seizures

HIV/AIDS

Depression/Anxiety

Cancer/Systemic Disease

Diabetes

Arthritis

Asthma

Cold Sores

Lupus

Headaches/Migranes

None

Other

Any known allergies?

Aspirin

Shellfish

Tree Nuts

Pollen

Latex

Lidocane

Dairy

Fruits

Fragrance/essential oils

Sunscreen

None

Other

List medications/supplements you are currently taking.

Have you ever received any botox or fillers? if so, where and when?

Have you ever experienced claustrophobia?

Yes

No

Please rate your stress level.

Low

Medium

High

None

What are your skin concerns?

What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)

Sensitive (reactive to fragrance, often irritated)

Combination (oily and dry patches, oily t-zone, hormonal breakouts)

Acne (cystic or nodules)

Oily (enlarged pores, excessive oil)

Dry (dull, visible lines and wrinkles, feels tight

What skin care products do you use on a daily basis?

Soap

Toner

Mask

Eye Cream

SPF

Cleanser

Serum

Exfoliant (physical or chemical)

Moisturizer

Vitamin A (retinol)

Do you experience routine breakouts or acne?*

Yes

No

Have you ever been diagnosed with eczema, psoriasis or rosacea?*

Yes

No

Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaring

Threading

Laser/Electrolysis

Do you currently use:

Accutane

Retin-A

Prescribed topical cream

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)

Vitamin A derivative (retinol/retonids)

BHA (salicylic acid)

Exfoliating Scrubs

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month

YES, within the last 2-3 months

NO

Do you?

Wear contact lenses

Have metal implants

Consume Alcohol

Frequent Tanning Beds

Have a pacemaker

Smoke

Consume Caffeine

Are you taking birth control?*

Yes

No

Are you pregnant or breast-feeding?*

Yes

No

I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “No-show” policy.*

Yes I agree

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Chateau Glow and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.*

Yes I agree

By typing your full name below you agree and sign acknowledging that you agree with the above terms and conditions*

Facial Consent Form

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