New Customer CHHF + General Consent Form

  • New Customer - Confidential Health History Form

  • Date of Birth*
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  • Do you consent to have parts or the full treatment filmed for Pele Bonita Spa's social media?*

  • BODY HEALTH

  • Have you had any of these health conditions in the past or present? (Please check  all that apply and provide additional information in the space provided)*
  • Do You Smoke?
  • Rows

  • AT HOME SKIN CARE

  • What Skincare Products Are You Currently Using?*
  • Are You Currently Using Products That Contain The Following? Select All That Apply.*

  • PREGNANCY

  • Terms & Conditions

    By filling out and submitting this form, you (the client) fully understand, read and answered this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the aesthetician/skincare therapist of my current medical or health conditions and to update this history. The treatments that I receive here are voluntary and I release this institution and/or skincare professional from liability and assume full responsibility thereof.

  • General Consent Form

  • I   *   *   hereby consent to and authorize Natasha Dresar (esthetician) to perform the following procedure:   *   
    I have voluntarily chosen to undergo this treatment/procedure after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved, by Natasha Dresar (esthetician). 

    Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results, that independent results are dependent upon age, skin condition, and lifestyle, and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.  

    I have read and understood the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the aesthetician 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 have read and fully understand this agreement and all the information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the aesthetician (Natasha Dresar) responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.

    I understand that the email address and phone number submitted will and can be used to communicate promotions, service updates, and general communication between you and Pele Bonita Spa.

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