ENCOUNTER BEAUTY

Date*

Date

Name*

First NameLast Name

Date of Birth *

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Emergency Contact & Phone Number*

How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral

If referred, by who?*

Are you currently under the care of a Physician?*

YESNO

Have you experienced any of these health conditions in the past or present?*

Any Allergies?*

List Medications/Supplements you are currently taking.*

Have you recently received Botox or Fillers? If so, what areas and when?*

Have you ever experienced Claustrophobia?*

YESNO

Please rate your stress level!*

LowMediumHighNone

What are your skin concerns?*

What would you say your skin type is?*

Normal (minimal to no visible blemishes, fine pores, smooth texture)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Dry (dull, visible lines and wrinkles, feels tight)

What skin care products do you use on a daily basis?*

Do you experience routine breakouts, inflamed acne or PCOS?*

YESNO

Have you been diagnosed with Eczema, Psoriasis or Rosacea?*

YESNO

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

Waxing/SugaringThreadingLaser/ElectrolysisNONE

Are you currently using any products that contain:*

AHA (Glycolic Acid, Lactic Acid, Mandelic Acid, Malic Acid, Tartaric Acid, Citric Acid)BHA (Salicylic Acid, Willow Bark, Meadowsweet)Vitamin A Derivative (Retinol/Retinoids/Retin-A/Tretinoin)Exfoliating Scrubs, EnzymesAccutaneOther Prescribed ExfoliantsNONE

Have you recently received any Mechanical/Chemical Exfoliations Treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO

Do you?*

Are you taking Birth Control?*

YESNO

Are you Expecting or Breast-Feeding?*

YESNO

How is your Diet, Water Consumption & Activity Level?*

What is your career and does it affect your skin's health?*

ENCOUNTER BEAUTY CONSENT TO TREAT

I give consent for all present and future Skincare and Body Treatments by Nirene Pomales, Licensed Esthetician and/or other Licensed Skincare Specialists affiliated under the Encounter Beauty Empire network.

I consent that the answers I have given are correct and that I have not withheld any information, medical conditions or contraindications that may be relevant to my treatment.

I release Nirene Pomales, Licensed Esthetician and/or other Licensed Skincare Specialists affiliated under the Encounter Beauty Empire network, it's beauty partners, colleagues, staff and current location, Facesology Skincare & Wellness Spa of any liability associated with any past, current and future adverse reactions resulting from my Skincare, Body Treatment Procedures or Products elected.

ENCOUNTER BEAUTY POST TREATMENT ACKNOWLEDGEMENT

I acknowledge that Skincare and Body Treatments are strictly an Elective Aesthetic Procedure and no medical claims have been expressed or implied.

I acknowledge after Dermaplaning, Microneedling, Chemical Peels and most Advanced Skincare Treatments my skin may experience temporary tightness, redness or slight swelling which usually dissipates within 72 hours depending on my skin's sensitivity and if I'm allergic to one or more of the ingredients, I may experience an allergic reaction.

I acknowledge if I fail to use a minimal Broad Spectrum Physical Sunscreen (SPF30), I am susceptible to sunburn, skin damage & hyperpigmentation. I also understand I should avoid excessive sun exposure immediately after my Advanced Skincare Treatments for a minimum of 2 weeks especially between the hours of 10am-2pm.

I acknowledge that I should avoid the use of Vitamin A type products, aggressive exfoliators, waxing, and products containing other exfoliating agents for a minimum of 1-4 weeks following the treatment or until I am advised by my Esthetican to resume.

I acknowledge I have been advised of my applicable Skincare & Body Treatment Post Care Requirements including Products, Nutrition, Supplements, Active Lifestyle & Water Intake that should not supercede any medical advice or recommendations from a medical professional. I should also seek guidance if I have a medical condition or any concerns regarding my health & wellness during my treatment plan. I have been advised of additional Pre/Post Home Care that is posted on the Encounter Beauty Empire Home Page for any further inquiries or concerns I should have outside of normal business hours. In the event of an emergency, I understand I should immediately contact a medical professional.

ENCOUNTER BEAUTY BEFORE/AFTER PHOTO CONSENT

I authorize any photography taken of me for treatment progress documentation and results to use, reuse, publish, and republish the photographs in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration. I release and discharge Encounter Beauty Empire LLC from any and all claims and demands that may arise out of or in connection with the use of the photographs, including without limitation any and all claims for libel or violation of any right of publicity or privacy. This authorization and release shall also inure to the benefit of the heirs, legal representatives, licensees, and assigns of Photographer, as well as the person(s) for whom he/she took the photographs.

I am a legally competent adult and have the right to contract in my own name. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.

For Exceptional Service, we ask that you kindly acknowledge and adhere to:

SPA SERVICE/EB DESTINATION EVENTS, ADVANCED CLINIC OPERATION PROTOCOLS & ETIQUETTE.

Please note: If receiving services at FACESOLOGY location, their SPA POLICY can be found at: www.facesology.com/policies Phone: 813-278-8834

SKINCARE/BODY TREATMENT REGIMEN - 80% of your results consist of adequate and consistent Home Care. It is imperative that you are diligent with a Skincare/Body Treatment Regimen in order to accomplish optimum results and desired goals. If you forget the Pre/Post instructions given for any Advanced Treatments, please visit our EB Home Page and click the Pre/Post Home Care link.

CANCELLATION POLICY - We kindly request Cancellations be done with at least 24 Hours Notice. Failure to do so will result in the loss of your Package Promotion, Deposit or 100% of your total Beauty Service/Advanced Aesthetic Course cost. NO SHOWS will automatically result in the loss of a package or 100% of the total Beauty Service/Advanced Aesthetic Course cost.

TO RESCHEDULE OR CANCEL your appointment, please log in to your EB Guest Profile and select your desired options.

TARDINESS - We recommend arriving prior to your scheduled time in order for our schedule to run smoothly and efficiently for our Guest and Beauty Service Providers. After 15 minutes of tardiness, either your appointment time will be shortened or subject to be rescheduled with a “Cancellation Penalty" of a 50% Beauty Service cost.

ADDITIONAL SPA GUEST - We reserve the right to ask your spa guest to wait for you outside of our spa due to limited space and complete spa tranquility. Please note, children under the age of 13 are not permitted in the spa for safety precautions and conducive spa ambiance, anyone between the age of 13-17 receiveing a service should be accompanied by a parent.

ENCOUNTER BEAUTY PASSPORT MEMBER appointments are all Pre-Paid Monthly and cleared by our Spa Concierge once payment status is confirmed. Payments are conveniently drafted monthly from your choice of a credit/debit card or paid in person the month prior at your previous visit. If your rebook is not cleared and cancelled by our Spa Concierge after you have made an appointment, please contact us via email: encounterbeautypros@gmail.com to confirm if your EB BEAUTY PASSPORT is current. Please Note: Memberships are limited to a certain number of clients and can be forfeited if canceled by you with a waiting period to be re-entered based on availability.

ENCOUNTER BEAUTY DESTINATION PACKAGES, ADVANCED AESTHETIC COURSES & TREATMENT PACKAGES are all paid in advance and non-refundable.

NEED FURTHER ASSISTANCE? Call/Text us at (813) 640-9003 or Email: encounterbeautypros@gmail.com - Please keep in mind, we may be dedicating our time to other Spa Guests, however will return your message at our earliest convenience.

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ENCOUNTER BEAUTY CLIENT HISTORY & CONSENT

Your Medical History

Your Skin

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