Rose Esthi | Facial & Treatments General Consent Form

Today's Date

Date Of Birth

Gender *

Email *

Address

Street Address *

City

State

Country

Postal Code

Phone *

If referred, by who?

Your Medical History

Are you currently under the care of a physician? *

YES

NO

List any medications / supplements you are currently taking

Have you ever received any botox or fillers? if so, where and when?

Have you ever experienced claustrophobia?

YES

NO

Please rate your stress level

Low

Medium

High

Your Skin

What are your skin concerns?

What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)

Combination (oily and dry patches, oily t-zone, hormonal breakouts)

Acne (cystic or nodules)

Sensitive (reactive to fragrance, often irritated)

Oily (enlarged pores, excessive oil)

Dry (dull, visible lines and wrinkles, feels tight)

Have you received any of these facial hair removal services in the last 7 days?

Waxing / Sugaring

Threading

Laser / Electrolysis

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)

BHA (salicylic acid)

Vitamin A derivative (retinol/retinoids)

Exfoliating scrubs

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month

YES, within the last 2-3 months

YES, over 3 months ago

NO

Do you have lice?

YES

NO

Do you give me permission to post your photo testimonial (picture) on social media after treatment?

YES

NO

I'm ready for my treatment.

I acknowledge these policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. I acknowledge that ANY no-show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy

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 (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure specially between 10 am-2 pm.

I acknowledge that this treatment is strictly an 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 not part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Rose Esthi and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

By checking this box, I consent to receive both transactional and marketing or promotional messages via text message and phone call from Rose Skincare (Only for ladies), including automated, pre-recorded, or AI-generated voice communications. These may include special offers, discounts, new product updates, and other relevant communications from your business. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt out at any time.

Client Signature *

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