Facial Treatment Consultation and Consent Form - QT Beauty&Aesthetics-HERTFORD

1.Client Information

Full Name

Date of Birth

Address

Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

2.Medical History
Skin Health

(Please specify)

Medical Conditions

(Please specify):

Allergies

(Please specify):

Medications and Treatments

Are you currently taking any medications (oral or topical)? (Include prescriptions, over-the-counter drugs, vitamins, and supplements)

Yes No

If yes, please list:

Have you recently used any of the following?

Retin-A, Renova, or other retinoid products Accutane or other isotretinoin products Alpha Hydroxy Acids (AHAs) or Beta Hydroxy Acids (BHAs) Steroids or anticoagulants Photosensitizing medications

Lifestyle Factors

Do you smoke tobacco or use nicotine products?

Yes No

Do you consume alcohol?

Yes No

If yes, how often?

Are you pregnant or breastfeeding?

Yes No N/A

Do you have any metal implants or a pacemaker?

Yes No

Previous Treatments

Have you had any of the following treatments in the past 6 months? (Please tick all that apply)

(Please specify):

3.Skin Care Routine

4. Treatment Goals

(Please specify):

5. Consent and Acknowledgement
Treatment Information

I acknowledge that I have been informed about the facial treatment, including:

*The nature and purpose of the treatment.
*The potential benefits and expected outcomes.
*Possible risks, side effects, and complications.
*Pre-treatment and post-treatment care instructions.

Photography Consent (Optional)

Yes, I consent to photographs being taken before and after my treatment for: My client record Marketing and promotional purposes (identity will be kept confidential) No, I do not consent to photographs being taken.

9. Client Signature
By signing below, I acknowledge that I have read and understood all the information in this consultation and consent form. I agree to the terms herein and consent to receive the facial treatment.