Consent form - Absolute

Name

Date of Birth

ADDRESS

CITY

STATE

ZIP

PHONE

Sex

Male Female

Does your job require that you work outdoors?

No YEs

How were you referred to us?

Occupation

What would you like to achieve from your treatment today?

Have you ever had a facial treatment before?

No Yes

When

Have you ever had a body spa treatment before?

Yes No

If yes, please specify when and what treatment:

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

Do you have any special skin problems or concerns pertaining to your face or body?

Yes No

Yes If yes, please specify:

Have you ever had chemicals peels, laser treatments, or microdermabrasion?

Yes No

In the last month?

Yes No

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?

Yes No

If yes, please specify what and when last used:

Have you used acne medication?

Yes No

when?

Which medication?

Have you experienced Botox, Restylane, or collagen injections?

Yes No

If yes, please specify:

What skin care products are you currently using? (List brands if known)

Cleanser

Toner

Day Moisturizer

Night Moisturizer

Exfoliator

Mask

Eye Product

SPF/Sunscreen

Scrubs

Makeup Products

Soap

Shower Gels

Body Lotions

Other

Have you used any hair removal methods in the past six weeks?

Yes No

Lips (Check all the apply)

Dehydrated Cracked/chapped lips Other

Have you ever had an allergic reaction to any of the following (Check all that apply)

Yes No

What SPF do you use on your face?

How often/when?

Have you recently used any self-tanning lotions, creams or treatments?

Yes No

If yes, please specify

Have you had any recent tanning bed or sun exposure that changed the color of your skin?

Yes No

If yes, please specify

How many glasses of water do you drink per day?

<1 glass 1-3 glasses 4-7 glasses 8+ glasses

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?

None 1-2 drinks 3-5 drinks 6+ drinks

How many alcoholic beverages do you consume per week?

I don’t drink 1-3 drinks 4-7 drinks 8+ drinks

Which foods do you consume on a regular basis?

What does your daily commute look like?

How often do you travel on a plane?

How many hours do you spend in front of a screen or digital device?

Do you exercise on a regular basis?

No Yes

Do you smoke cigarettes, vape, or consume other tobacco products?

No Yes

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?

Are you taking oral contraceptives?

No Yes

If yes, please specify:

Any recent changes to or from your contraceptive treatments?

No Yes

If yes, please specify what and when

Are you pregnant or trying to become pregnant?

No Yes

Are you experiencing any menopausal symptoms?

No Yes

If yes, please specify

Are you undergoing any hormone replacement therapy treatments?

No Yes

If yes, please specify

Do you experience irritation from shaving?

No Yes

If yes, please specify

Do you experience ingrown hairs as a result of hair removal?

No Yes

May I call you at the provided phone number to confirm future appointments?

No Yes

May I contact you via mail/email about future promotions and news?

No Yes

May I contact you via mail/email about future promotions and news?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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 here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Client Name (Printed)

Client Name (Signature)

Date:

Contact Us