CONSENT SERVICES FORM

Treatment Consent Form

Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ Eyelash ㅤ✶ㅤ Brow ㅤ✶ㅤ Lips ㅤ✶ㅤ Facial ㅤ✶ㅤ Headspa ㅤ✶ㅤ Fairy Lashes & Brow ㅤ✶ㅤ

CLIENT INFORMATION FORM

Name *

Birthday *

Email *

Phone *

Address *

What are your specific skin care concerns? (select) *

Dry Skin Age Spots/Sunspots Fine Lines Oily Skin Redness Sensitive Skin Black Heads Acne Hormonal Acne Uneven Skin Tone

What skin care products are you currently using?
Please answer to the best of your ability:

BRAND *

AM Skin Care Routine

Cleanser *

Toner *

Exfoliation or Scrub *

Serum *

Moisturizer *

Sunscreen *

Eye Cream *

Other Products or Rx *

PM Skin Care Routine

Cleanser *

Toner *

Exfoliation or Scrub *

Serum *

Moisturizer *

Sunscreen *

Eye Cream *

Other Products or Rx *

MEDICAL HISTORY

Are you pregnant, lactating, or plan on becoming pregnant soon? *

Yes No

List all known allergies (food, products, ingredients, etc.) *

Have you ever had a reaction to skin care products or ingredients? *

Yes No

Are you using any prescribed exfoliants? (Retin-A, Epiduo, Differin, Renova, Accutane, etc.) *

Yes No

Are you currently taking any medication that could interfere with a facial treatment? *

Yes No

HEALTH & SKIN CONDITIONS

CLIENT ACKNOWLEDGEMENT

Please select to Indicate Your Acknowledgement *

I understand that Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face and provide light exfoliation. The nature and purpose of Dermaplaning has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure. I understand that the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness, mild irritation, and dryness. Additionally, nicks to the skin can occur due to the sharp surgical blade. If a chemical peel is included with this treatment, I understand that the sensation and penetration of the peel will be enhanced. This may cause skin irritation, mild discomfort, tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores, when virus is already present in the body.

CHEMICAL PEEL CONSENT

Chemical Peel: Please Initial to Indicate Your Acknowledgement *

I understand my Esthetician will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions. I understand that, very rarely, permanent damage occurs I have given an accurate account of any over the counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my Esthetician. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

WAXING & PHOTO CONSENT

Waxing Consent: Please select to Indicate Your Acknowledgement *

I have given an accurate account of any over the counter or prescription medications that may interfere with my waxing service, such as to Accutane, Retin-A, Differin, Renova, blood thinners, high antibiotic use, Retinol and alpha-hydroxy products. I understand that it is my responsibility to bring up any questionable products that I may be using. I also understand that dry skin or regular skin sensitivity may cause irritation or tearing of the skin during a waxing service

Photo Consent: Please select to Indicate Your Acknowledgement *

By checking this box, I authorize the salon and its affiliates the right to capture, reproduce, and use my photographs and/or videos taken before, during, and after my treatment/service. These materials may be utilized for advertising, promotional, educational, or other commercial purposes across any media platforms, including but not limited to, social media and websites. I understand and agree that no additional compensation will be provided for the use of these materials. Furthermore, I waive any rights to review or approve the final content wherein my likeness appears.

FACIAL TREATMENT CONSENT

Consent for Facial Treatment: Please select to Indicate Your Acknowledgement *

I understand that redness, sensitivity, peeling or other reactions may occur from a facial treatment. I further understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment. I understand that facial results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type, condition, degree of sun/environmental damage, pigmentation levels, or acne condition. I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I certify that I am at least 18 years of age, or I have a parental consent co-signed below.

Client Consent & Acknowledgment *

I certify that I have read the above consent and I fully understand it and give my consent to treatment. The treatments I receive here are voluntary and I release Fairys Lashes And Brows and/or the Esthetician from liability and assume full responsibility thereof.

Printed Name *

Date *

Treatment on a Minor: Please select Yes to Indicate Your Acknowledgement *

Yes No

Signature *

Fairy - Nederland Tx

Fairy - Lumberton Tx

Business hours

Treatment Consent Form

CLIENT INFORMATION FORM

AM Skin Care Routine

PM Skin Care Routine

MEDICAL HISTORY

HEALTH & SKIN CONDITIONS

CLIENT ACKNOWLEDGEMENT

CHEMICAL PEEL CONSENT

WAXING & PHOTO CONSENT

FACIAL TREATMENT CONSENT

Contact us

Business hours

Fairy - Nederland Tx

Fairy - Lumberton Tx

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