Consent Forms | Elysiumskinandbeauty

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Skin Treatment & Medical History Consent Form

To ensure that we can provide you with the best possible care, we kindly ask that you complete the attached form. The information you provide will help us tailor our services to your specific needs and offer a more personalized experience.

Please fill out the following form.

First name*

Last name*

Date of birth*

Year

Month

Day

Phone

Email*

Address

How did you hear about us?

If you chose referred Please name the person who referred you. (Referral Program)

Yes, subscribe me to your newsletter.

Are you currently pregnant or breastfeeding?

Do you have any skin or medical conditions? ex: Cold Sores, Diabetes, HIV etc*

Have you ever been diagnosed with skin cancer or currently undergoing treatment for it?*

Do you currently have any fungal skin diseases or infections? (Athletes Foot, Ringworm etc)*

Do you suffer from any of the following inflammatory skin conditions? ( check all that apply)

Psoriasis

Atopic dermatitis (eczema)

Pemphigus

None

Please List any medications you are taking, including vitamins and supplements.*

Do you have any known allergies? ex: Shellfish, Seafood etc*

Have you received Botox, Restylane, Or any facial injections in the las 2 months?*

If Yes to either of these questions, Please Explain Below

Have you used or been prescribed any acne medication in the last 12 months?*

Have you had any facial Treatments in the last 7 days?*

What current skincare product(s) do you use? (please include Brand and Product name/type)

What are your main skin concerns? Do you have any other Concerns you would like to share?

I consent to receiving facials, peels, and other skin treatments. I understand the treatments may involve various procedures and acknowledge that results can vary. I release Elysiumskin&Beauty from any liability related to the treatments.

I consent to the use of my photo/video for marketing and promotional purposes by Elysiumskin&Beauty. I understand that these materials may be used in various media, including online platforms.

Date and time

Year

Month

Day

Time

:HoursMinutes

Signature*

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I declare that the info I’ve provided is accurate and complete.

OPENING HOURS

Monday, Tuesday, Thursday Friday

4:00PM – 8:00 PM

Wednesday

10:00AM – 8:00 PM

Saturday/Sunday

9:00AM – 3:00 PM

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Email: Elysiumskinandbeauty@gmail.com

Tel: 780-994-8910

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Monday - Friday

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