SEAWEED PEEL CONSENT FORM

SEAWEED PEEL CONSENT FORM

Thank you for choosing EN Signature Brow and Beauty studio for your services. We love to give every client the best quality service. Please fill out the form below.
This form is designed to provide information for making an informed decision regarding your peel. If you have any questions, please do not hesitate to ask your esthetician. While peels are effective in most cases, no guarantee can be made for individual results.
Name:

First NameLast Name
Occupation:
Sex:
Age:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Skin tone
Eye Color
Hair Color
Do you wear contacts?
Do you have permanent makeup? If so, where?
Have you had a peel before?
Describe your skin choose all the apply:
Do you consider your skin Sensitive or Tolerant?
Do you have dilated capillaries or spider veins on your face?
Are you sun or wind-burned?
When was the last time you tanned?
When was the last time you had facial hair removed?
Are you pregnant?
Trying to get pregnant?
Have you had an “injectable” treatment from a Physician recently?
If "Yes", When?
Are you recently facially post operative?
If "Yes", When?
Are you allergic to milk, apples, citrus, grapes, aloe vera, aspirin or hydraquinone?
Any other allergies?
Are you using any of the following:
How frequently?
Are you taking hormones, birth control?
What kind?
Please list all medications (prescription and OTC)
Have you ever had an adverse product reaction?
Describe
Do you smoke?
Do you drink caffeine?
How Much?
Do you drink Alcohol?
Do you get cold sores/ blisters?
Do you take medication for cold sores/ blisters?
What is your skin care regime?
What about your skin bothers you and what would you like to have corrected or improved?
Check and Agree with the following:
I am 18 years old or older
No I am not 18 years old. I have parental and/or guardians consent with a signature. By signing below you understand the possible risks with this service.
Print Parental/Guardians name:
first and last name
Signing below I agree I understand in full the information presented above, and freely give consent to under go the peel procedure. All questions have been answered to my complete satisfaction. The undersigned acknowledge the potential risks of a peel procedure and, except for damage resulting from the sole gross negligence of Elizaveta Neginskaya LLC. ,I agree to release Elizaveta Neginskaya LLC. & its employees and agents from any claim or liability arising out of this service.
REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for your self or for another individual are absolutely non-refundable. This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.
Date

MonthDayYear
Date
Please fill out email to receive after care instructions.
example@example.com
Should be Empty: