Âme Skin Studio Consent Form

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Name* Please, this field is requiredplease add the name of the person receiving the treatment

First Name

Last Name

Please share your pronouns. I want to know how to respectfully refer to you!* Please, this field is required

Date of Birth* Please, this field is required

Date

Email* Please, this field is required

example@example.com

Address* Please, this field is required

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Mobile Phone Number* Please, this field is required

Area Code

Mobile Phone Number

Do you have a discount code?If yes, please write it below

special code

If this appointment is a gift certificate, please write down the gift certificate number; If you received the gift certificate in person, please write down "certificate" and bring it to the appointment.* Please, this field is requiredIf it's not a gift certificate, please write "n/a". GIFT CERTIFICATES (NUMBER OR THE CERTIFICATE ITSELF) MUST BE PRESENTED AT THE TIME OF THE APPOINTMENT, OR THE APPOINTMENT WILL BE CHARGED IN FULL.

How did you hear about Âme Skin Studio and/or Rosie Petrillo?* Please, this field is required

Walked by

Instagram

Online Search

Facebook

Yelp

Google

Referral

Other

If referred, by who?* Please, this field is required

Are you currently under the care of a physician?* Please, this field is required

YESNO

Have you experienced any of these health conditions in the past or present?* Please, this field is required

Hormone Imbalance

Cancer/Systemic disease

High Blood Pressure

Diabetes

Heart problem

Arthritis

Auto-immune Disorder

Asthma

Epliepsy/Seizures

Cold sores

HIV/AIDS

Lupus

Depression/Anxiety

Headaches/ Migranes

None

Any known allergies?* Please, this field is required

Aspirin

Fruits

Latex

Shellfish

Lidocaine

Fragrance/essential oils

Tree Nuts

Dairy

Sunscreen

Pollen

Other

None

List medications/supplements you are currently taking* Please, this field is requiredIf none, please type "none"

Have you ever received any botox or fillers? if so, where and when?* Please, this field is requiredIf never, please type 'never"

Have you ever experienced claustrophobia?* Please, this field is required

YESNO

Please rate your stress level* Please, this field is required

Low

Medium

High

None

Have you had a facial before?* Please, this field is required

YESNO

What are your skin concerns?* Please, this field is required

What would you say your skin type is?* Please, this field is required

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)

What skin care products do you use on a daily basis? ** Please, this field is required

Cleanser

Serum

Toner

Mask

Eye Cream

Moisturizer

SPF

Vitamin A (Retinol, Retin-A)

Alpha Hydroxy Acid (AHA)

Exfoliating Scrub

Beta Hydroxy Acid (BHA)

Accutane

Prescribed Topical Cream

None

Do you experience any breakouts or acne?* Please, this field is required

YESNO

Have you ever been diagnosed with:* Please, this field is required

Eczema

Psoriasis

Rosacea

None

Have you received any of these facial hair removal services in the last 7 days?* Please, this field is required

Waxing/sugaring

Threading

Laser/Electrolysis

None

Have you ever received chemical peels, laser services, or microdermabrasion treatments?* Please, this field is required

Yes, within the last month

Yes, within the last 2-3 months

Yes, over 4 months ago

Do you...* Please, this field is required

Wear contact lenses

Have a pacemaker

Have metal implants

Smoke

Consume Alcohol

Consume Caffeine

Frequent tanning beds

None

Photo Consent* Please, this field is required

I give permission for photos or videos to be taken throughout the course of my treatment

I do not give permission for photos or videos to be taken throughout the course of my treatment

Are you taking birth control?

YESNO

Are you pregnant or breastfeeding?

YESNO

By marking a statement, you agree with its affirmation* Please, this field is required

I acknowledge that my skin may experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 24-36 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 and/or hyperpigmentation.

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 at least 1 week following treatment.

I release Âme Skin Studio and its staff of any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.

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.

This consent form will expire within 365 days of the date completed. I acknowledge that if any of my medical history has changed I will inform my Esthetician.

Have you experienced any of the following symptoms of COVID-19 (fever, chills, sore throat, shortness of breath/difficulty breathing, runny nose, loss of taste or smell or experienced flu-like symptoms)? * Please, this field is required

YESNO

Are you currently waiting for results from a COVID-19 test? * Please, this field is required

YESNO

Have you been in contact with someone who has test positive for COVID-19 or has experienced flu-like symptoms? * Please, this field is required

YESNO

Have you traveled either internationally or outside of Connecticut in the last 14 days? * Please, this field is required

YESNO

Informed ConsentPlease mark all statements you agree with

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing.

I recognize that Âme Skin Studio and it’s staff are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment that has been scheduled, and I give my express permission for Âme Skin Studio and its staff to proceed with the same.

I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment, it can lead to a higher chance of complication and death.

I have been given the chance to ask questions or to defer my treatment to a later date. However, I have read the above informed consent to treat and understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19. I knowingly and willingly consent with full understanding and disclosure of the risks, and would like to proceed with my desired treatment.

Signature* Please, this field is requiredPlease type your name between two single forward slashes: Ex: /Jane Doe/

Signature* Please, this field is required

Âme Skin Studio Consent Form