electronic skincare consent waiver

Please fill your name: *

Please enter your full name.

Date of Birth: *

Please enter valid date.

Phone number: * Please enter your phone number.

Email: * Please enter your email.

Referred by: * Please enter your answer here.

How would you rate your stress level from 1 to 10? (10 being the highest) * Please enter your answer here.

What would you like to achieve from your treatment today? * Please enter your answer here.

Have you ever had a facial treatment before? *

No

Yes, once.

I get them here and there.

I love facials and try to get them whenever I have time.

Please select at least one choice above.

Which of the following best describes your skin type? Please choose one. *

Creamy Complexion - Always burns easily, never tans

Light Complexion - Always burns, tans slightly

Light/Matte Complexion - Burns moderadely, tans gradually

Matte Complexion - Seldom burns, always tans well

Brown Complexion - Rarely burns, deep tan

Black Complexion - Never burns, deeply pigmented

Please select at least one choice above.

Do you have any metal implants in your body? If yes, please state where. * Please enter your answer here.

Do you have any special skin problems or concerns pertaining to your face or body? * Please enter your answer here.

Have you had chemical peels, laser, microdermabrasion or micro needling in the last month? *

No

Yes

Please select at least one choice above.

Do you use Retin-A, Renova, Adapalene Hydroxl Acid or Retinol/vitamin A derivative products? Please state yes or no. If yes, describe: * Please enter your answer here.

Have you ever used an acne medication? *

No

Yes

Please select at least one choice above.

If yes, which one(s) and were they used within the last 3 months? * Please enter your answer here.

What skin care products are you currently using? (list brand where known) * Please enter your answer here.

What areas of concern do you have regarding your skin? Please check any that apply. * Please select at least one choice above.

Have you ever had an allergic reaction to the following? * Please select at least one choice above.

Are you taking oral contraceptives? *

No

Yes

Please select at least one choice above.

Are you pregnant or trying to become pregnant? *

No

Yes

Please select at least one choice above.

May I call or text you at your cell phone number to confirm future appointments? *

No

Yes

Please select at least one choice above.

May I contact you via email/mail about future promotions and news? *

No

Yes

Please select at least one choice above.

Initial Here

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. * Please click the yellow area and provide your initials here.

Electronic skincare consent waiver- a digital skin waiver signed online.