Facials Consultation & Consent Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Emergency Contact Name & Number:
How did you hear about us?
Referral by Someone Social Media Website Walk-in Other
Medical History
Please check all that apply:
Diabetes High blood pressure Low blood pressure Heart condition Epilepsy or seizures Thyroid condition Hormonal imbalance Pregnant or nursing Metal implants / pacemaker Recent surgery (within 6 months)
Allergies (Please list)
Medications (especially Accutane, Retin-A, antibiotics): _
Other conditions we should be aware of
Skin History & Current Routine
What is your skin type?
Oily Dry Combination Sensitive Normal Unsure
Primary skin concerns
Acne / Breakouts Hyperpigmentation Fine lines / Wrinkles Dehydration Redness / Sensitivity Uneven texture Dark circles Other If yes, please describe:
Current skincare routine (brands/products): Have you had a facial before?
[radio* cskincareroutine use_label_element "Yes" "No"] If yes, when was your last facial?
Do you use any of the following?
Retinol / Retinoids AHAs / BHAs / Glycolic acid Benzoyl Peroxide Exfoliants (scrubs, peels) Sunscreen If yes, how often?
Do you wax or use hair removal creams on your face?
Yes No If yes, when was your last treatment?
Treatment Goals & Expectations
What are you hoping to achieve with today’s facial treatment?
Are there any areas of your face you’d like us to focus on or avoid?
Client Acknowledgement & Legal Consent
I, the undersigned, confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that the services provided at Derma Direction are intended for cosmetic and wellness purposes only and are not a substitute for medical care.
I have disclosed any and all known allergies, sensitivities, medical conditions, and use of medications.
Facial treatments may involve skin manipulation, product application, steam, and exfoliation, which carry minimal risk of irritation, allergic reaction, or temporary redness.
I agree to follow aftercare instructions provided by my esthetician and understand that results may vary based on individual skin type and compliance.
I understand that my information will be kept confidential in accordance with California privacy laws and industry standards.
Yes, I give my informed and voluntary consent to receive facial treatments from a licensed esthetician at Derma Direction.
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