I understand, have read and completed this questionnaire to the best of my knowledge. I agree that this documentation constitutes full disclosure, and that it supersedes any previous verbal or disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin form treatment received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. All of the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting my Esthetician to any physical or mental condition which would affect my
I understand my treatment is therapeutic in nature and will alert my Esthetician to any discomfort. I understand and acknowledge that there are risks involved with the treatment of facials, peels, microdermabrasion, microcurrent electrical skin treatments, brow and lash tinting as well as waxing.
PLEASE NOTE THAT WAXING CAN HAVE CERTAIN SIDE EFFECTS SUCH AS SKIN
REMOVAL,REDNESS,SWELLING,BRUISING,TENDERNESS,ECT.THESE ARE ALL NORMAL REACTIONS.
I have had the opportunity to ask questions regarding these risks and other possible complications. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby waive Cactus WAX Studio LLC and the Esthetician's liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications, or effects and hereby waive Cactus WAX Studio LLC Esthetician's liability if such results or complications occur. and the In consideration for Cactus WAX Studio LLC and the Esthetician performing this procedure, I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure is performed. I understand that the Esthetician does not diagnose illness, disease, or any other physical or mental
To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against the Esthetician, Cactus WAX Studio LLC, it's service providers, owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. I agree that this waiver and release shall bind the members of my family and any spouse or domestic partner, if I am alive, as well as my estate, family, heirs, administrators, personal representatives or assigns if I am deceased, and shall be deemed as a "Release, Waiver, Discharge and Covenant" not to sue Cactus WAX Studio LLCorany of it's service providers.
MAXIMUM LIABILITY: Cactus WAX Studio LLC MAXIMUM AGGREGATE LIABILITY TO PATIENT
RELATED TO OR IN CONNECTION WITH THE PROCEDURE PERFORMED BY Cactus WAX Studio LLC, ITS EMPLOYEES, OR AGENTS WILL BE LIMITED TO THE TOTAL AMOUNT PAID TO Cactus WAX Studio
LLC BY CLIENT FOR THE PROCEDURE DESCRIBED IN THIS AUTHORIZATION AND CONSENT.