Covid-19 Facial Services Consent Form

Covid-19 Facial Services Consent Form

The following information must be signed and dated prior to your arrival at MaddTan LLC. By signing this form you agree that you have sought services out at your own free will and accept all risks pertaining to the current pandemic.
Client Name *

First Name Last Name
Date *

Month Day Year
Date
By checking the boxes, you confirm that you agree with the following statements: *

I understand that I may have a higher risk of contracting the virus during the Facial service as I will be required to remove my mask. I agree to obey the rules of the salon during my appointment in order to minimize the spread of viruses. ( Masks are required upon arrival and will be removed by your esthetician.) I confirm that I have not been diagnosed with COVID-19 in the last 14 days. I verify that I am not waiting for the laboratory test results for COVID-19. I agree to notify MaddTan LLC if I begin to have symptoms or are urged to be tested for Covid-19 within 14 days of my treatment. I understand that MaddTan LLC will take my temperature upon arrival, will wear masks and gloves for my treatment, and abides to all sanitary and disinfection processes as advised by the cdc and their state board. I understand that if my tempature is above 100.4 I will be rescheduled, without exception. I attest I have not traveled out of New Mexico within the last 14 days. I WILL CONTACT MADDTAN IF I BECOME ILL WITHIN 14 DAYS OF BEING SEEN!!!!!!!
Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell *

Yes No
Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or get infected? *

Yes No
Are you living with anyone that is infected or quarantined due to COVID-19? *

Yes No
I agree not to visit the salon for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form. I fully understand that any services I receive at MaddTan LLC are elective and sought out by myself thus releasing MaddTan LLC from any liability of contracting covid-19.
Client/Parent/Guardian Signature *

Clear
Facial Intake and Consent
Are you currently under the care of a Physician? *

Yes No
Have you experienced any of these health conditions in the past or present? *

Hormone Imbalance High blood Pressure Heart Problems Auto Immune Epilepsy/Seizures Hiv/Aids Cancer Dieabetes Asthma Cold Sores Lupus Blood Disease none
Any Known Allergies? (example: latex, shellfish,aspirin,zinc) *
Please List ANY AND ALL medications and or Supplements you are taking. *
Have you received Botox or Fillers within the last 18 months? If so when and where? ( please list which areas of the face have been treated) *
Have you received ANY facial Hair removal services in the last 7 days? ( I.E. Waxing, Sugaring, Threading or laser?) *
Have you experienced claustrophobia? *

yes no
Are you currently using any of the following products *

Retin-A / Retinol / Vit A Accutane Any topical prescriptions prescribed by a physican AHA (glycolic acid, lactic acid, etc.) BHA (salicylic acid) Exfoliating scrubs I dont know what any of this is dee, is it almost over?!
Are you currently using any of the following products

AHA (glycolic acid, lactic acid, etc.) BHA (salicylic acid) Vitamin A derivative (retinol/retonids) Exfoliating scrubs
Do you

Wear contact lenses Smoke Consume Alcohol Consume Caffeine Frequent tanning beds
Are you

Pregnant or Breast Feeding Taking Birth Control
If you are taking birth control, what type? If pregnant how far along, are you high risk?
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 (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure for 72 hours.

I acknowledge that this treatment is strictly 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 no part of the recommended take-home regimen for 2 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 MaddTan LLC and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Signature *

Clear
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Covid-19 Facial Services Consent Form

Facial Intake and Consent