Client Consent Form

Rosie Glow Skincare

First Name

Last Name

Date of Birth

Address

Phone

Emergency Contact Name

Emergency Contact Phone

Please list any concerns that you have with your skin

What skincare products are you currently using?

Have you been under the care of a physician, dermatologist, or other medical professional within the past year?

Yes

Do you use Adapalene, Glycolic Acid, Accutane, Retin-A, Renova, Deferin, Salicylic Acid or any retinol product (Accutane)?

Do you have any allergens (food, cosmetics, sunscreen, etc...)?

How did you hear about Rosie Glow?

Have you ever experienced claustrophobia?

Yes

I understand, have read and fully completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that not all treatments will have the same results on every client, therefore no guarantee can be given. I also understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform Rosie Satorius of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Rosie Glow Skincare and my esthetician from liability and assume full responsibility thereof.

Your Signature

Date

Thanks for submitting!

Client Consent Form

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