Studio Soothe Skin Care Consent Form
PLEASE USE TAB KEY TO MOVE TO THE NEXT BOX AFTER ENTERING YOUR INFORMATION. PRESSING “ENTER” OR “RETURN” WILL SUBMIT AN UNFINISHED FORM. THANK YOU!
Name
First Name
Last Name
Actual Date of your Service
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number. Preferably a cell that we can text you for appointment confirmation and to invite you inside when we are ready for you.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
Name of the Therapist for your appointment. If you don’t know answer N/A
Who can we thank for telling you about us?
Have you had a facial before? If so, when was your last one?
Are you pregnant?
Do you have any medical problems? If yes, please explain.
Are you on any medications?
Have you had any surgery or serious illness in the last year?
Are you allergic to Latex, any products, oils or foods? (Like nuts?)
Have you ever had a reaction to any skin care product? If yes, what kind of reaction did you have?
Within the last year have you been under a Dermatologist’s care? If yes, what conditions were being treated?
Do you have Eczema or Psoriasis? If so where?
If applicable, do you understand this service may irritate your Eczema or Psoriasis? (Though we will take great care to try not to let that happen!)
Do you have any warts? Most people don’t realize these are contagious. This will not affect whether you receive your service or not. We would need to take proper precaution or avoid the area.
What are your favorite scents? Floral, Citrus, Spice, Woody, Other?
When lying still do you get: Hot, Cold, Not Sure?
Do you wear contact lenses?
Are you claustrophobic?
Are you sensitive to steam?
What skin type do you think you have? Oily, Combination, Dry, Extremely Oily, Extremely Dry
Do you consider your skin sensitive? If yes please tell us what type of sensitivity you have? For example: Prone to break out, redness, reactionary
Have you had any chemical peels, dermabrasion or any resurfacing treatments in the past year? If so please give the type and date of last treatment.
Do you use any topical prescriptions like Retin A, Adapalene, Epiduo or any other prescription skin products? If so, please list them and date you last applied to your face, neck or decollete
Any oral medications prescribed specifically for skin by Dermatologist or Doctor? Spironolactone? Oral antibiotics? Accutane?
Are you currently using any products containing the following ingredients: Alpha Hydroxy Acids, Glycolic Acid, Lactic Acid, Malic Acid, Tartaric Acid, Mandelic Acid, Scrubs or Retinols? Please list and date of last use.
Have you had Botox, Collagen or any other injectable fillers in the past month? If so please list them and the location of injections.
Please list products you are currently using. Cleanser, exfoliation, toner, moisturizer, sunscreen etc. Brand names too if you know them.
Please tell us any concerns you have about your skin or any priorities you'd like us to focus on
Please initial the following:
You understand you are responsible for payment of 100% of the cost of this service now and in the future if you cannot make your appointment or cancel inside of the 24 hour window of your scheduled appointment.
You agree to call us or email us with at least 24 hours notice if you need to cancel your appointment.
You certify that you do not have any special occasions, weddings or any other important event within TWO WEEKS of this appointment. You completely understand that skin care, massage therapy and waxing can potentially cause skin reactions and Studio Soothe cannot be held responsible for any reaction you may have as a result of your service. If you wish to reschedule you may do so outside our 24 hour cancellation policy window.
I understand that if I choose to still have my appointment within two weeks of my “special event” as listed above, Studio Soothe will ask that a Waiver of Liability be signed after the completion of this form. After finishing this consent form please return to the Form page and fill out the Waiver of Liability.
You understand if you are verbally abusive or sexually suggestive to anyone at Studio Soothe you will be asked to leave and charged 100% of the cost of the service.
You understand that you are a participant at Studio Soothe and While your therapist will check in on you, it is up to you to communicate with us if we are using too much pressure or if any of our products don’t feel right to you. We are hear to help and we often refrain from talking to give you a chance to relax!
If you are unhappy with your service or your practitioner, or any other issue at Studio Soothe you will contact us via our contact page at studiosoothe.com or call us to let us know. (Thank you!)
Communicating with us allows us to address your needs, concerns and fix our mistakes and offer better services to you and our other clients in the future. We appreciate all feedback!
Please initial that you are 18 years of age at the time of this service.
I knowingly and willingly consent to having facial/skin care service(s) now and in the future during the COVID-19 pandemic.
To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the Studio Soothe’s strict COVID-19 guidelines. https://www.studiosoothe.com/covid19-information
I agree not to come to the salon with the following symptoms UNEXPLAINED within 24 hours of your service. Symptoms of COVID-19 listed below: Fever, Temperature, Shortness of breath, Loss of sense of taste or smell, Dry cough, Runny nose, Sore throat. If I have any of these Unexplained symptoms I will call Studio Soothe asap 415-674-7511 to reschedule my appointment at no charge. Please help us after 10 months of closure to do this as soon as you possibly can. We much appreciate the help and effort.
I verify I have not traveled outside the United States In the past 14 days before the date of my service.
I understand that while Studio Soothe is in compliance with city/ county/ state guidelines and diligent in their Capacity limits, Proper PPE and cleaning that entering any facility is a risk and we cannot guarantee you will not contract COVID-19.
Today’s date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: