Real Beauty by Shaina
Skin care consent
How did you hear about us?
Conditions you are currently experiencing today (Please select all that apply):
Which aroma(s) do you prefer? (Please select all that apply)
What type of skin do you have?
What areas of concern do you have regarding your skin?
Uneven Skin Tone
Sun, Brown Spots
Have you been under the care of a dermatologist within the past year?
If yes, please explain
Have you ever had an allergic reaction to any of the following?
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA’s or Retinol/Vitamin A derivative products?
If yes please describe:
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
If yes, please specify:
By signing below, you agree to the following:
I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information.
I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable.
I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly.
I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
Guardian Signature (under 18)