ESSpa Spa Services Consent Form
By submitting this form, you acknowledge that you have provided truthful answers to the questions below in order to have hair, skin, nail or body services delivered at ESSpa Organic Hungarian Skincare + Salon.
Client Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
?
Yes.
No.
By checking the boxes, you confirm that the following statements are true:
*
I agree to follow all ESSpa rules and protocols (written and/or verbal) during my visit/appointment in order to minimize the spread of viruses.
I agree to tell my ESSpa Professional(s) what I want and expect from my service(s) during the duration of my visit.
I understand the risk of unintentional exposure to virus while visiting ESSpa.
I understand that I may experience adverse results if I choose to not follow my ESSpa Professional's "at-home" products and care recommendations.
Do you have any of these symptoms? (check all that apply):
*
Fever (above 100.1)
Cough.
Muscle/Joint Pain.
Loss of Taste and/or Smell.
Shortness of Breath..
Nausea.
Unusual or extreme tiredness.
None of the Above
I will not enter ESSpa (spa or salon) if I am sick. I understand and agree that it is my responsibility to inform ESSpa staff if I am sick for any reason.
*
Agree
Do you have any issue(s) - medical or otherwise - that we should be aware of that might impact your visit to ESSpa?
*
Yes
No
If "Yes" above please explain
Are you currently taking Retin A, Accutane, Trentoin or using any type of Retinol product (prescription or OTC) or any other photosensitive product?
Yes
No
If "Yes" above please tell us what type of Retinol-based product you are currently taking.
Are you currently taking any prescription or other OTC medication(s)?
*
Yes
No
If "Yes" above please tell us what you are currently taking.
Do you have any allergies? (food, airborne, bees, seafood, latex, etc.)
*
Yes
No
If "Yes" above please explain the details.
What Service are you scheduled for today?
*
Please Select
Facial
Massage
Waxing / Tinting
Manicure
Pedicure
Hair Color
Hair Cut
Other
What results are you expecting to see/feel from your visit to ESSpa today?
*
Please Check Box and then Sign Below:
*
I will abide by all ESSpa rules and protocols (posted or otherwise) and I hereby indemnify and release ESSpa, its owners and employees from any and all liability from unintentional exposure or harm due to any virus or illness.
I Understand that any services I receive at ESSpa are provided for the basic purposes of relaxation and that ESSpa Service(s) should not be inferred and/or construed as a substitute for medical examination, diagnosis, or treatment and nothing said in the course of my appointment should be considered as such.
I agree that I have clearly provided all my known medical conditions and answered all questions honestly and I agree to inform my ESSpa Service Provider of any changes in my medical and/or health status.
I agree, to the best of my knowledge, to give an accurate account of my medical history, including all known allergies or prescription drugs, products or supplements I am currently ingesting or using topically.
I have read and fully understand this agreement and all information detailed above. I understand the procedure(s) and accept any and all risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.
I will not hold my Service Provider or Eva Kerschbaumer or ESSpa or staff, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected in any way by the treatment performed today
I agree to pay in full for any and all appointment(s) scheduled by/for me on the date of service. If I do not show for a scheduled appointment(s) without giving 24 hours notice, I agree to pay for any service(s) I was originally scheduled for.
By signing below, I confirm that all the personal statements in this form are true and valid and willingly provided by me without coercion.
Parent/Guardian Name (if applicable)
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Client/Parent/Guardian Signature
*
Submit
Should be Empty: