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All required fields must be completed.

Have you ever had any of these treatments?

If yes when did you get them? Did you have any complications?

Are you currently using any of the following ?

Can I take before / after pictures for you and use it on social media?

Consent Form for Virtual and in Person Treatments

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and therefore I release this business and/or affiliated skin care professional from liability and assume full responsibility thereof. I hereby consent to and authorize MySkinByMichelle to obtain personal and past information for the purposes of skin care recommendations. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understood this agreement and all information detailed above. I understand and accept the risks. I consent to the terms of this agreement. I do not hold MySkinByMichelle responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.