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Facial
Questionnaire
Full Name
Cell Phone
Email
Address
Date of birth
Are you currently pregnant or breastfeeding?
*
Yes
No
Maybe
Are you currently using a tanning bed?
*
Yes
No
Please list any allergies you are aware of.
Please list any medications you are currently on.
What are your skin concerns and what would you like to focus on during your appointment?
Acne
Anti-aging
Hyperpigmentation
Texture/Rough Skin
Healthy Skin/Understanding a good routine
Relaxation
Dark circles/Puffy Eyes
Would you like a free consultation with your facial treatment?
No
Yes
Please list any products you are currently using and the frequency of use. Daily, Nightly, sporadically.
I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may need more than one treatment.
I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, condition of the skin, sun damage, smoking and climate.
I may or may not experience actual "peeling" with certain procedures, as each case is individual.
I understand that there may be some degree of discomfort i.e. stinging, "pin-pricking" sensation, hotness or tightness.
I understand that although complications are very rare, sometimes they may occur, and that prompt treatment is necessry.
I agree to refrain from tanning or excessive sun exposure while I am undergoing certain treatments and 14 days after my treatment.
I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sunblock protection with a minimum SPF 30 is reccommended.
I will reveal any medical conditions that may affect the treatment such as pregnancy, cold sore tendencies, allergies, injectables, recent facial peels, laser or surgery, or pacemakers.
Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six-twelve months prior.
I have not had a peel treatment of any kind within 14 days of my facial.
I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by the M&M staff.
Prior to receiving treatment, I have been candid in revealing any condition that may influence this procedure as outlined.
I will also inform M&M of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.
In the event of any questions or concerns, I will consult my esthetician immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the esthetician and M&M harmless from any liability that may result from this treatment. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above statements and that I have had sufficient opportunity for discussion to have any questions answered.
I hereby grant Mix and Makeup permission to photograph me as an assistance for my service treatments. I understand that these photographs will help document the progress of my treatments. I hereby authorize and consent to the above described photography and understand several photographs may be needed to document my treatment.
I declare that the info I’ve provided is accurate & complete
Signature
Submit
Thanks for submitting!
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