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General Consent Form

I consent to

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 skin care professional from liability and assume full responsibility thereof.


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. I understand all pre/post treatment instructions and I understand the importance of following the instructions given to me. I hereby consent to any treatments offered at Vixen Esthetics (Chemical Peels, Dermaplaning, Hydrofacials, Microneedling, Waxing, DMK Enzyme Therapy, DMK Alkaline Wash, & all other treatments offered at Vixen Esthetics). Although it is impossible to list every potential risk and complication, I understand that there are risks, benefits and complications associated with any/all treatments. I understand that Vixen Esthetics will not be held liable for any complications, reactions, or side effects that may occur and I am agreeing to undergo all treatments provided by Vixen Esthetics at my own risk.


Although rare, allergic reaction to the pigment and procedure may occur.

I Agree



Today's Date: May 14, 2025

First Participant's Name

First Name*

Last Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
First Participant's Signature*
Second Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Third Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Fourth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Fifth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Sixth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Seventh Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Eighth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Ninth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Tenth Participant's Name

First Name*

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

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.

How Did You Hear About Us?*:

If Referral, Please Name:
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*
Parent or Guardian's Information
Gender*

Ethnicity: *

Current Homecare Routine:

Allergies (Please list all): *

Medications taking - Including antibiotics (Please list all): *
Are you currently pregnant and/or breastfeeding?*
No
Yes

Last Botox/ Filler apppt (Leave blank if this does not apply)

Last skincare treatment - please describe what you got (leave blank if this does not apply)
Have you been on accutane?*
No
Yes

If answered yes, when?
Have you used retinol in the past week?*
No
Yes

If answered yes, when?
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Endometriosis
PCOS
None
Other
Do you?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Are you a smoker? *
No
Yes
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks) *
No
Yes
Are you taking birth control? *
No
Yes
N/A

If yes, what kind?
Are you pregnant or trying to become pregnant?*
No
Yes
N/A
Recently had a baby and am breastfeeding*
No
Yes
N/A
Any menopause issues? *
No
Yes
N/A

If yes, please specify:
Are you undergoing any hormone replacement therapy?*
No
Yes

If yes, please specify
“Before and after” photos will ALWAYS be taken to track our progress, and document to your file at Vixen Esthetics. Photos will ONLY be posted/used for advertizing if you consent to this, via signature below. I consent to "before & after" photographs for the purpose of documentation, potential advertising, and promotional purposes.*
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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