Customer Consent Form | Demanew Skin Lab

First name

Last name

Email

Phone

Birthday

Month

Day

Year

How did you hear about us?

Is this your first facial treatment?

Yes

No

What are your current skin concerns?

Are you under a physician's care for a skin condition or other problem?

Yes

No

If yes, for what condition or problem?

What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)

Combination (oily and dry patches, oily t-zone, hormonal breakouts)

Acne (cystic or nodules)

Sensitive (reactive to fragrance, often irritated)

Oily (enlarged pores, excessive oil)

Dry (dull, visible lines and wrinkles, feels tight)

Do you experience routine breakouts or acne?

Yes

No

Have you ever been diagnosed with eczema, psoriasis or rosacea?

Yes

No

Have you or will you receive any of these facial hair removal services within 7 days of your booked facial?

Waxing/ Sugaring

Threading

Laser/ Electrolysis

No

Do you currently use?

Accurate

Retin-A

Prescribed topical cream

None

Are you currently using any products that contain:

Have you or will you receive a chemical peel or laser treatment within 8 weeks prior to your booked facial?

Yes

No

Are you pregnant or breast-feeding?

Pregnant

Breast Feeding

No

Please rate your stress level.

None

Low

Medium

High

Your preferences during facial treatments?

I prefer no talking during treatments

I enjoy hearing about treatment steps and product ingredients

I acknowledge that I must adhere to the polices and that all treatment cancellations must be done with at least 24 hours notice. Failure to do so will result in the loss of your service booking deposit. I acknowledge that ANY no show forfeits my deposit.

I understand that I may have some discomfort, redness, swelling, itching, irrittion, skin peeling or flaking after a facial treatment. If I experience any pain or discomfort during the session I will immediately inform the esthetician so that products and/or technique may be adjusted for comfort. I also understand that a facial is not a substitute for a medical examination, diagnosis or treatment.

Because certain treatments should not be performed under certain medical conditions, I understand that the esthetician reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which facial treatments are contraindicated.

I acknowledge facial treatments are elective skincare services and no medical claims have been expressed or implied.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my facial treatment and give consent for all future treatments.

I release Demanew Skin Lab and staff of any liability associated with any injury, allergic reactions, or any skin abrasions as a result of the services performed on me or current and future conditions resulting from any treatments or products.

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Date

Month

Day

Year

Demanew Skin Lab Intake & Consent Form