Dermalogica Facial – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details: *

If you had any allergie or other medical condition please specify :

Do you have any metal implants or pacemaker? *

Yes

No

Are you currently using any topical/oral medications (e.g., Retin-A, Accutane)? *

Yes

No

If yes, list medications and duration:

Treatment Goals and History

What is your primary concern regarding your skin *

Have you had any cosmetic procedures within the last 3 months (laser, fillers, peels)? *

Yes

No

If yes, please lest us know :

Do you use SPF daily? *

Yes

No

Treatment Expectations & Preferences

Have you had a professional facial before *

Yes

No

If yes, when was your last treatment?

What are your goals with today’s Dermalogica facial?

Are there any specific products or ingredients you wish to avoid? *

Yes

No

If yes, please list:

Risks, Side Effects, and Acknowledgements

Please you should read and initial each statement regarding Dermalogica Facial : *

I understand that a Dermalogica facial is a non-invasive skincare treatment designed to improve the health and appearance of the skin.c

I acknowledge that temporary redness, sensitivity, or breakouts may occur post-treatment.

I agree to disclose all skin sensitivities and allergies prior to treatment.

I understand that individual results vary and this treatment is not a cure for skin conditions.

I will follow all home care instructions and recommendations provided by the practitioner.

I understand that it is my responsibility to inform the practitioner of any discomfort during the session.

I consent to photos being taken for documentation purposes. These will not be shared without written permission.

24-Hour Cancellation Policy:

We require a minimum of 24 hours' notice for any appointment cancellations or rescheduling. Failure to provide at least 24 hours' notice, or missing your scheduled appointment, will result in the forfeiture and deduction of that session from your pre-paid package.