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Metropolitan Day Spa

 

Facial Treatment Consent Form

Consent Agreement

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability on the provider and Metropolitan Day Spa should I fail to do so.

My questions regarding the treatment have been answered satisfactorily.  I understand the treatment and accept any risks. I hereby release the provider and Metropolitan Day Spa from all liabilities associated with the above indicated treatment.    

I agree that this consent supersedes any previous verbal or written disclosures.  This consent is valid for all of my facial treatments in the future as well.

Today's Date: June 1, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information

Health Related:

Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you wear contact lenses?*
No
Yes

*Remove contacts prior to microdermabrasion or if eyes are sensitive.

Do you wear sunscreen on a regular basis?*
No
Yes
Have you visited a tanning booth within the last week?*
No
Yes

*If so, your service may have to be rescheduled.

Are you currently taking any antibiotics?*
No
Yes

No (may increase sensitivity.)

Skin Care Related:

Are you currently using products containing
Glycolic Acid
AHA
How long have you been using the product and how has your skin been reacting to it?
Are you currently using Accutane?*
No
Yes
If yes, how long?
Have you ever used Hydroquinone (skin lightener)?*
No
Yes
How long ago?
Do you currently use wax, electrolysis or depilatories on your face?*
No
Yes
If so, when was your last treatment?
Have you had any of the following?
Microdermabrasion
Chemical Peel
Laser Resurfacing
Collagen or Botox
Facial Surgery
If items checked above, please list and when
Do you have permanent make up?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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