Imperfection Treatment Confidential Consent

Imperfection Treatment Confidential Consent

Ritual Beauty
A 24 hour notice is required if you need to cancel or reschedule your session. Cancelling or rescheduling less than 24 hours ahead will result in a fee equal to 50% of the session total. Failure to arrive to a session will result in a fee of 100% of the session total.

Appointments will be adapted for guests running late without adjustment to pricing. This may result in forgoing certain aspects of the session to remain on schedule. Guests arriving more than 5 minutes (4-10 spot) 15 minutes (30 minute session) late may need to be rescheduled with a fee that is equal to 25-50% of reserved session.

Thank you in advance for your consideration~
As always, my priority is your health and safety. I will be wearing a mask and limiting the guests I see daily. Masks are not required for guests.

There is no special preparation for your appointment, however, please refrain from wearing heavily scented lotions, perfumes, or excessive jewelry.

When you arrive, please do not enter the spa more than 5 minutes before your appointment unless requested to do so.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Would you like to be notified of specials and monthly promotions?

YesNo
If using Groupon, please list voucher number
What imperfections would you like treated:*
Do you regularly use sunscreen?*

YesNo
Sunburn in the last week?
Please list any allergies; including foods, medication, latex, iodine, etc:*
Are you currently pregnant or postpartum?
Please list any auto-immune and/or health conditions:*
Are you currently under the care of a medical practitioner, if yes please explain:*
Please list all current medications and any taken within last month:*
Please check current as well as past conditions that have affected your health:*

DiabetesCancerPacemakerKeloid ScarringThyroid or Hormonal ConditionHepatitisNone of the Above
Please select any areas you would like more information on:

At Home Skincare RecommendationsAdvanced Anti-AgingLash EnhancementsBrow EnhancementsAcne ManagementSkin Tone Correction
I acknowledge the treatment goal is for esthetic improvement, and the number of treatments will vary between individuals as well as areas being treated.
Healing time can vary between individuals as well as area(s) being treated; approximately 7-10 days on average. Crusting will initially occur, followed by drying and sloughing of the area. Please note, complete healing time can be up to 3-4 weeks.
I acknowledge that no guarantee has been made about the results of the treatment.
I acknowledge that proper use of broad-spectrum sun protection and avoiding direct/extended sun exposure will assist in achieving desired results.
I have been informed of the possible risks which may include, but not limited to:
Redness, Minor Swelling, Pitting, Scabbing

Please avoid the following:
• Rubbing, Picking, or Scrubbing.
• Extended exposure to water or steam; long baths/showers, swimming or soaking (7 Days).
• Sweating, strenuous activity or sun overexposure.
•Use of Retinoids, Bleaching Serums, or Other Exfoliating Agents until skin is healed.
Thank you for taking the time to complete this intake form. All information and treatments are confidential.

I understand the importance of informing my technician of all medical conditions and medications I am taking and disclose any changes to these. I understand that there may be additional risks based on my physical condition(s). Services are not a substitute for medical treatments or medications. I have read, understand, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and supersedes any previous verbal or written disclosures. I understand withholding information may result in contraindications from the treatment received. The treatments I receive are voluntary and I release Ritual Beauty and Nina Aviles Skin Care from any liability and assume full responsibility thereof. For the purpose of documentation photographs may be taken before and/or after your treatment. Photos are available upon request.

I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly. I understand that I or the technician may terminate the session at any time.
With my consent I may be contacted by phone, email or text message for the purposes of appointment reminders and treatment communications.
Signature

Clear
Should be Empty: