Pretty Please Haus of Vanity

Date *

Date

Name *

First Name Last Name

Email

example@example.com

Phone Number *

Area Code Phone Number

Why are you here today? *

Eyebrow Embroidery Lip Embroidery Laser Hair Removal Acne Treatment HIFU Treatment Others

How did you hear about us? *

Walked by Facebook/Instagram Online Search (Google etc.) Referral

If referred, by who?

Are you currently under the care of a physician or feeling unwell? *

YES NO

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

Any known allergies? *

List medications/ supplements you are currently taking.

Have you ever received any botox or fillers? If so, where and when?

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?

YES NO

Have you been diagnosed with eczema, psoriasis or rosacea?

YES NO

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

Waxing/sugaring Threading Laser/Electrolysis

Do you currently use:

Accutane Retin-A Prescribed topical cream None

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month YES, within the last 2-3 months NO

Do you?

Wear contact lenses Have a pacemaker Have metal implants Smoke Consume Alcohol Consume Caffeine Frequent tanning beds

Are you pregnant or breast-feeding? *

YES NO

Disclaimer

I acknowledge that I must adhere to R&R Beauty Studio's policies.

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.

All services are non-refundable, but we will be more than happy to schedule corrective services free of charge. The service must be a mistake from R&R Beauty Studio and not due to change of mind after the service has been performed.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 96 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 (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-4pm.

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 2-4 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 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.

Signature

Clear

Service/Treatment Consent Form

Your Medical History

Your Skin

Females Clients