Skincare Treatments – Client Information and Consent
Name
Address
|  |  |  |  |  |  |  |  |  |  |  |  |  | 
| City |   |   |   |   | State |   |   | Zip |   |   | 
| Phone |   |   | E-mail |   |   |   |   |   |   | 
| How did you hear about us? |   |   |   |   |   |   |   |   |   |   | 
| Employer ___________________________________________________________________________________________________ Occupation | ___________________________________________________________________________________________________________________________________________ | 
What would you like to achieve from your skin treatment today? ______________________________________________________________________________________________________________________________________________________________
Skin Care History
Have you ever had a facial treatment or chemical peel before? __________ Yes __________ No
Which of the following most closely describes your skin type?
| I | Creamy Complexion | Always burns easily, never tans | 
| II | Light Complexion | Always burns, may tan slightly | 
| III | Light / Matte Complexion | Burns moderately, tans gradually | 
| IV | Matte Complexion | Seldom burns, always tans well | 
| V | Brown Complexion | Rarely burns, deep tan | 
| VI | Black Complexion | Never burns, deeply pigmented | 
Do you have any special skin problems or concerns? ______________________________________________________________________________________________________________________________________________________________________________________
Do you use Retin-A, Renova, or Retinol/vitamin A derivative products? __________ Yes __________ No
Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours? __________ Yes __________ No
Are you currently taking Accutane or have you taken it in the past? _________ Yes __________ No How long ago? _____________________________________________
Have you used other acne medication? __________ Yes __________ No If yes, which one? ________________________________________________________________________________________________________________________________________
Are you exposed to the sun on a daily basis or do you use a tanning bed? __________ Yes __________ No
What skin care products are you currently using? Please list the brand if known:
| Cleanser _____________________________________________________________________________ | Toner ____________________________________________________________________________________ | 
| Mask ___________________________________________________________________________________ | Moisturizer _________________________________________________________________________ | 
| Eye Product _______________________________________________________________________ | SPF _________________________________________________________________________________________ | 
| Exfoliation / Scrubs __________________________________________________________ | Night Cream _______________________________________________________________________ | 
| Treatment / Acne product ____________________________________________ | Makeup Brand ___________________________________________________________________ | 
 
 
 
| Please circle any areas of concern you have regarding your skin: |   | 
|   | Breakouts / Acne | Blackheads / Whiteheads | Excessive Oil / Shine | 
|   | Rosacea | Broken Capillaries | Redness / Ruddiness | 
|   | Sun spot / Brown spots | Uneven Skin Tone | Sun Damage | 
|   | Wrinkles / Fine Lines | Dull / Dry Skin | Flaky Skin | 
|   | Dehydrated Skin | Sensitive Skin |   | 
| Eyes: | Dark Circles | Puffiness | Fine lines | 
| Please circle if you have ever had an allergic reaction to any of the following: |   | 
|   | Cosmetics | Medicine | Food | 
|   | Animals | Sunscreens | Pollen | 
|   | AHAs | Fragrance | Shellfish | 
|   | Latex | Collagen | Other: ___________________________________________________________________________________________________ | 
Have you ever had Botox, Restylane, or other injections? ______________________________________________________________________________________________________________________________________________________________________________
Ladies only:
Are you taking hormonal contraceptives? __________ Yes __________ No
Are you pregnant or trying to become pregnant? __________ Yes __________ No Are you nursing? __________ Yes __________ No
Experiencing any menopause problems? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Are you undergoing any hormone replacement therapy or cancer treatments? ____________________________________________________________________________________________________________________________________
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. The skin care treatments I receive at Belle Waxing and Skincare are voluntary and I release Belle Waxing and Skincare from liability and assume full responsibility thereof.