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Facial Consent Form


By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred. I understand that there is the possibility of some reactions to occur such as redness, irritation, and bruising. I also give consent for my credit card on file to be charged $25 in the event of a missed appointment or cancellation with in 24 hours.

April 15, 2025

First Participant's Name

First Name*

Middle Name

Last Name*

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

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

How did you hear about us
What type of skin do you have?
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Sun, Liver, Brown Spots
Other
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain:
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
AHAs
Fragrance
Latex
Other

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, Accutain Retinol/Vitamin A derivative products, or antibiotics?


If yes please describe:

Other medications:
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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