Back Home

Facial Consent Form

Facial Consent Form

Please click on link and read. Then choose Advances Therapies Option below for consent.

Consent Form for Advanced Therapies

Please fill out ALL personal info as some people have the same name.

We want to be sure the health info is connected to the correct profile.

Health history for Facial services
Email address
Birth Date
Skin Type
Are you currently under a physician's care?
List any surgeries you had within the last 9 months
Medications, Vitamins, and or special concerns pertaining to your skin?
What skin care products are you currently using?
Do you experience breakthrough oily shine during the day?
Do you experience skin breakouts?
Have you or do you?
Do you have any metal implants in your body?
How much water do you consume daily? (ex. ounces)
Do you ever experience these conditions?
Do you use sunscreen, sun block, SPF?
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
Have you suffered sinus problems?
Are you Claustrophobic?
What massage pressure do you prefer?
Have you had recent dental X-Rays?
I give consent for facial services.
I give consent for Advanced Therapies and Enzyme Facials