Pretty Please Haus of Vanity

Terms of Service Agreement / Consultation Form

Please read and fill in carefully
Date*

DayMonthYear
Date
Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
Why are you here today?*

Eyebrow EmbroideryLip EmbroideryLaser Hair RemovalAcne/Pigmentation TreatmentSkin TighteningOthersWhitening Treatment
How did you hear about us?*

Walked byFacebook/InstagramOnline Search (Google etc.)Referral
If referred, by who?
Your Medical History
Are you currently under the care of a physician or feeling unwell?*

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

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigrainesNoneOther
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther
List medications/ supplements you are currently taking.
Have you ever received any botox or fillers? If so, where and when?
Your Skin
What are your skin concerns?
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
Do you experience routine breakouts or acne?

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/Electrolysis
Do you currently use:

AccutaneRetin-APrescribed topical creamNone
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Do you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Females Clients
Are you pregnant or breast-feeding?*

YESNO
TERMS OF SERVICE & LIMITATION OF LIABILITY

If you select "No" to any of the questions below, please alert our staff
I understand that results may vary based upon the circumstances and individual's skin type and conditions. Testimonials or statements made by any person(s) are not intended to substitute for pre-treatment discussion or evaluation or as a guarantee as to outcomes. Examples of treatment outcomes shown are not intended to convey and warranty, either express or implied, as to the outcome or benefits from treatment. The customer should assess the risks and benefits of such procedures after consultation, before accepting any treatment.*

YesNo
I hereby grant permission to R&R Beauty Studio and its representatives to take photographs and videos of me for the purpose of referencing during the course of treatment.*

YesNo
I understand that all services are non-refundable. R&R Beauty Studio will be more than happy to schedule corrective services free of charge, but the service must be a mistake from R&R Beauty Studio and not due to change of mind after the service has been performed or disappointing outcomes.*

YesNo
I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions and I agree not to hold R&R Beauty Studio and its representatives liable in such event.*

YesNo
I understand that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 96 hours depending on skin sensitivity. I understand that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-4pm. I understand 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 2-4 weeks following treatment.*

YesNo
I am aware that all treatments are strictly elective cosmetic procedure and no medical claims have been expressed or implied.*

YesNo
I hereby declare that the answers I have given are correct (to the best of my knowledge) and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.*

YesNo
I release R&R Beauty Studio, its representatives, agents, staff, and suppliers of ALL liabilities, claims, expenses, damages, and losses associated with any injuries and/or current and future conditions resulting from the beauty procedures or products.*

YesNo
Signature *

Clear
(By signing, you are deemed to have read, understood and accepted the clauses above)
Should be Empty:

Terms of Service Agreement / Consultation Form

Your Medical History

Your Skin

Females Clients