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Client Consent Form

Birthday
Okay to e-mail?
Yes
No
Which of the following best describes your skin type? (Please check one)
Type I Fair skin tones—Always burns, never tans
Type II Light skin tones—Burns easily, tans slightly
Type III Fair to olive skin tones—Burns moderately, tans moderately
Type IV Light brown skin tones—Burns slightly, tans easily
Type V Dark brown skin tones—Rarely burns, tans easily
Type VI Dark brown to black skin tones—Never burns, tans easily
Your Skin Type:
Do you wax your facial skin on a regular basis?
Yes
No
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing?
Yes
No
If yes, was it within the last Month?
Yes
No
Are you using Retin-A?
Yes
No
Are you using Benzoyl Peroxide?
Yes
No
Have you ever experienced a reactions to any of the following?
Do you have any of the below health issues?
Accutane?
Yes
No
Antibiotics?
Yes
No
Birth Control?
Yes
No
May I call you at the provided phone number to confirm future appointments?
Yes
No
May I contact you via mail/email about future promotions and news?
Yes
No

I have read and completed this questionnaire truthfully. 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 are voluntary and I release the company and /or skin professional from libaity.

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