New Client Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * How did you hear about us? * Referral Social Media Who referred you? Medical History Please check all that apply (current and in the past): Diabetes High Blood Pressure Heart Condition Hormone Imbalance Lupus Fever Blisters Shingles Acne Pregnant Seborrhea Hypo Pigmentation Hyper Pigmentation Hype/Hypo Thyroid Arthritis Eczema HIV Sinus Infection Warts Epilepsy Hepatitis Low Blood Pressure Rashes Skin Cancer Other Depression Anxiety Are you currently taking any medications? * Yes No If yes, please explain: Have you had any facial or dermatology services in the past 30 days? * Yes No If yes, please explain: Do you have any allergies? * Yes No If yes, please explain: Please rate your stress level * none low normal high Skincare History What would you consider your skin type? * Normal (pores barely visible, even skin tone, minimal skin sensitivities and blemishes) Dry (small pores, dull/rough skin, prone to redness and flaking) Oily (larger pores, shiny/greasy skin, may have more blemishes and blackheads) Combination (medium pores in T-zone, oily T-zone, may have blemishes and blackheads) Sensitive (fine/large pores, redness, itching, and dry skin, prone to irritation) What are your skin concerns? * Conditions you are currently experiencing today (please select all that apply): Anxiety Inflammation Fatigue Insomnia Forgetfulness Muscle Cramps Headaches Stress Have you been under the care of a dermatologist within the past year? * Yes No If yes, please explain: Have you been diagnosed with eczema, psoriasis or rosacea? * Yes No If yes, please state the skin condition: Have you used any of these products in the last three months? * Retin-A Renova AHAs Retinal Vitamin A Accutane Prescribed Topical Cream Tretinoin No, I have not used any of these products in the last three months. Have you received Botox, Restylane, or Collagen injections in the last 6 months? * Yes No Photograph and Video Release Agreement I grant and authorize Zabé Beauty the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Zabé Beauty from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate. Please read the statement above and initial to agree. * By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I 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 liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) I am more susceptible to sunburn, skin damage & hyperpigmentation. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2 weeks following treatment. I give consent for all future treatments I release Zabé Beauty liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products. Sign Name * Date * MM DD YYYY Thank you!
