Skin Evaluation Questionnaire

Skin Evaluation Questionnaire
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
Emergency Contact*
List full name and number of emergency contact.

I have voluntarily elected to undergo this treatment and understand the nature and purpose of this treatment, and are aware of possible benefits, risks, and complications.

I recognize there are no guaranteed results and that independent results are not only dependent upon age, skin condition and lifestyle but also commitment to the treatment plan and home care recommendations from the esthetician. I understand that there is the possibility I may require further treatment than orginally suggested to obtain my desired result.

I understand that the after care instructions for this treatment will be delivered to me via email post-treatment. I understand how important it is to follow all after care instructions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will contact the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand that all of my health information will remain confidential. I agree to keep the esthetician updated as to any changes in my medical history and understand that there shall be no liability on the esthetician's part should I forget to do so.
I consent to Miona Naturals: Esthetics + Spa to take photos and/or videos of me immediately prior to, during and/or after my procedure. I authorize Miona Naturals: Esthetics + Spa to copyright, edit, use and publish these photos and/or videos. I consent to Miona Naturals: Esthetics + Spa using such photos and/or videos for the purpose of documentation, education, social media, advertising and web content. I may indicate if I prefer not to have my full face shown. I understand that I will not receive any monetary compensation for usage of my photos and/or videos.

Yes
By signing below, I consent to and authorize Miona Naturals: Esthetics + Spa and the esthetician, Brittany Miona Ward, to perform my service. I acknowledge that I have read and fully understand this agreement and all information detailed above. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I hold the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, harmless from any liability that may result from this treatment. I understand rude or offensive behavior and language is NOT tolerated at any time and that the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, reserves the right to refuse service at any time.
Client/Parent Signature*

Clear
Esthetician Name
Date

MonthDayYear
Date
Should be Empty:

Skin Evaluation Questionnaire

Work Life Details

Your Health

Your Lifestyle

Your Routine