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Fill in a Valid Facial Consent Form

The Facial Consent form is a document designed to obtain permission from clients before performing facial treatments. It outlines the procedures involved, potential risks, and the client's rights, ensuring transparency and informed consent. This form serves as a crucial step in establishing trust and professionalism in the skincare industry.

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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

Document Information

Fact Name	Description
Purpose	The Facial Consent form is used to obtain a client's permission for facial treatments and procedures.
Legal Requirement	In many states, obtaining written consent is a legal requirement before performing cosmetic procedures.
Informed Consent	The form ensures that clients are informed about the risks and benefits associated with facial treatments.
State-Specific Regulations	Some states, like California, require specific language in consent forms as per the California Business and Professions Code.
Record Keeping	Practitioners must keep the signed consent forms on file for a specified duration, often for legal protection.

Completing the Facial Consent form is an important step before receiving treatment. Ensure that all information is accurate and legible to avoid any delays in processing your consent.

Begin by entering your full name in the designated field.
Provide your contact information, including your phone number and email address.
Fill in your date of birth in the specified format.
Indicate any relevant medical history by checking the appropriate boxes.
Read the consent statement carefully to understand the terms.
Sign and date the form at the bottom to confirm your consent.
Submit the completed form to the designated staff member or office.

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Dos and Don'ts

When filling out a Facial Consent form, there are important guidelines to follow. Here’s a list of things you should and shouldn't do:

Do read the entire form carefully before signing.
Do provide accurate personal information.
Don't rush through the process without understanding the terms.
Don't omit any medical history that could affect the treatment.

Common mistakes

Filling out a Facial Consent form may seem straightforward, but many individuals make common mistakes that can lead to complications or delays. Here’s a list of ten frequent errors to watch out for:

Omitting Personal Information:
Many people forget to include their full name, contact information, or date of birth. This information is crucial for identification and communication purposes.
Neglecting Medical History:
Failing to disclose relevant medical conditions or allergies can pose serious risks during the facial treatment.
Not Reading Instructions:
Some individuals rush through the form and miss critical instructions, which can lead to misunderstandings about the treatment.
Inaccurate Emergency Contact:
Providing incorrect emergency contact information can hinder communication in case of an unexpected situation.
Skipping Signature:
Some forget to sign the form altogether. A signature is necessary to validate consent.
Ignoring Age Requirements:
Individuals under a certain age may require parental consent. Not noting this can lead to complications.
Failing to Ask Questions:
Many do not take the opportunity to ask questions about the procedure or the form itself, which can lead to misunderstandings.
Incorrect Date:
Some individuals mistakenly fill in the wrong date, which can create confusion regarding the treatment timeline.
Not Disclosing Previous Treatments:
Failing to mention prior facial treatments can affect the current procedure and its outcomes.
Assuming Consent is Permanent:
Many believe that signing the form means they cannot change their mind later. It’s essential to understand that consent can be revoked.

By being aware of these common mistakes, individuals can ensure that their Facial Consent form is filled out correctly, leading to a smoother and safer experience.

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