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Esthetician Consent Form -Form Fill

Section One
Q1

Client Name

First Name
Q2

Client Name

Last Name
Q3

Date of birth

Date
Q4

Phone Number
Q5

Email
Q6

Address

Street Address
Q7

Address

Street Address Line 2
Q8

Address

City
Q9

Address

State / Province
Q10

Address

Postal / Zip Code
Q11

Esthetician's Name

First Name
Q12

Esthetician's Name

Last Name
Q13

Are you presently taking any medications?
Q14

Are you pregnant?
Q15

Do you have any allergies to cosmetics, food or drug?
Q16

What skin care products do you currently use?
Q17

Have you had skin cancer?
Q18

Do you use acne medication?
Q19

Are you taking oral contraceptives?
Q20

Please check if you are affected by or have any of the following
Q21

Client Signature
Q22

Date

Date