Fill in a Valid Facial Consent Form
Document Sample
Skincare Treatments – Client Information and Consent
Name
Address
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Phone |
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How did you hear about us? |
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Employer ___________________________________________________________________________________________________ Occupation |
___________________________________________________________________________________________________________________________________________ |
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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
Have you used any
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: |
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Breakouts / Acne |
Blackheads / Whiteheads |
Excessive Oil / Shine |
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Rosacea |
Broken Capillaries |
Redness / Ruddiness |
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Sun spot / Brown spots |
Uneven Skin Tone |
Sun Damage |
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Wrinkles / Fine Lines |
Dull / Dry Skin |
Flaky Skin |
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Dehydrated Skin |
Sensitive Skin |
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Eyes: |
Dark Circles |
Puffiness |
Fine lines |
Please circle if you have ever had an allergic reaction to any of the following: |
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Cosmetics |
Medicine |
Food |
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Animals |
Sunscreens |
Pollen |
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AHAs |
Fragrance |
Shellfish |
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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.
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Document Information
| Fact Name | Description |
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| 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. |
Facial Consent - Usage Guidelines
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:
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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.
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Neglecting Medical History:
Failing to disclose relevant medical conditions or allergies can pose serious risks during the facial treatment.
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Not Reading Instructions:
Some individuals rush through the form and miss critical instructions, which can lead to misunderstandings about the treatment.
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Inaccurate Emergency Contact:
Providing incorrect emergency contact information can hinder communication in case of an unexpected situation.
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Skipping Signature:
Some forget to sign the form altogether. A signature is necessary to validate consent.
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Ignoring Age Requirements:
Individuals under a certain age may require parental consent. Not noting this can lead to complications.
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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.
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Incorrect Date:
Some individuals mistakenly fill in the wrong date, which can create confusion regarding the treatment timeline.
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Not Disclosing Previous Treatments:
Failing to mention prior facial treatments can affect the current procedure and its outcomes.
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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.