Service Agreement Form

Name*

First NameLast Name

Date of Birth *

Date

Email*

example@example.com

Phone #*

Area CodePhone Number

How did you hear about us?*

Services & Treatments interested in:*

Date you would like to have service

Date

Are you currently under the care of a physician?*

YESNOOther

Have you experiences any of these health conditions in the past or present?

Any known allergies?*

List medications/supplements you are currently taking.

Have you ever received any Botox or fillers? if so, where and when?

What are your goals with your service?

What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)Other

What skin care products do you use on a daily basis?

Check any that apply to you.*

Rate your stress

	1	2	3	4	5

1 is Low & Calm, 5 is High Stress

Female Clients

Are you taking birth control, pregnant, or breastfeeding?

NOYes, i am taking birth control.Yes, i am pregnant.Yes, i am breastfeeding.

Male Clients

You may shave day before in beard area for complete treatment to that skin.

Do you experience ingrown hairs as a result from hair removal?

I understand, have read and completed 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.
The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
I acknowledge that my skin may experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.
I acknowledge that if I fail to use a sunblock (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.
I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.
I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment depending on my estheticians advice.
I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.

SCHEDULING POLICY PLEASE READ:

DEPOSIT NEEDED for booking.

A non-refundable fee of $50.00 is required for reserving a day and time specifically for you and your service. This fee will go towards your service total. Cash accepted. If service total is under $50.00, full payment required for booking. Appointment is not verified until deposit is received. You will be contacted for service to then proceed with deposit to reserve your time and day.

Appointments are given 20 minutes grace period, if you no call/no within that window, you will have to pay deposit again for future scheduling. Appointments are confirmed 24 hours before via email/text.

Appointments needed to reschedule has to do so within 48 hrs window (2 days notice before original schedled session) to keep deposit towards service.

By signing below, i confirm i am aware and will abide to the terms in which my appointment will be scheduled by.

Signature*

SERVICE AGREEMENT FORM

ABOUT YOU

YOUR SKIN

Female Clients

Male Clients

DISCLOSURE AGREEMENT