Skincare Intake Form

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Occupation

Robe Size*

E-mail address:*

MEDICAL CONTRAINDICATIONS

Are you currently under the care of a physician?*

YesNo

If yes, who is your physician?

Please take a moment to carefully read the following list of conditions and questions below. Check any that have affected your health either recently or in the past. A referral from your primary care provider may be required prior to service being provided.*

If you selected any of the above options, please explain.

Recent Ilness .

Contagious Conditions .

Pregnant/Trimester .

Skin Cancer Where/When .

Metal implants Location .

Surgeries What/When .

Any other health concerns .

Cancer .

Taking Medications .

Are you allergic to any cosmetic ingredient, medication or food? If yes, please list them:

SKIN CONCERNS

Please check any concerns regarding your skin:

Please List Other Concerns: .

Cleanser .

Toner .

Exfoliant .

Serum .

Moisturizer/Day .

Retinol/AHA/Glycolic .

Moisturizer/Night .

SPF .

Other please list: .

Please check the prescription medications you are currently using:*

Other please list: .

Please complete the following information as thoroughly and honestly as possible. Some of the questions that follow may seem unrelated to your condition. However, they may play a role in treatment. We would like to make your service as pleasant and comfortable as possible.

If at any time you have questions regarding your session, please let your practitioner know.

Please list all professional facial or dermatology services you have received in the past 30 days (i.e. Chemical Peel,Microdermabrasion, Laser, BOTOX®, other cosmetic injectibles, etc.):

Client Signature*

Date*

Before subjecting yourself to any skin treatment (s), read carefully the following statements. After you have read each statement, please initial each respective statement in the space that has been provided.

Initial Here* Theprocedure(s) has been explained to me in detail by the practitioner. For optimal results, I understand a homecare regimen is needed to enhance the results of a clinical peel.

Initial Here* I understand the is a skin rejuvenation treatment. I may need several administrations of this procedure in order to achieve my best results.

Initial Here* I understand the need not be administered by a physician. I am also comprehend that, the esthetician who administers the treatment has had his/her skills reviewed and endorsed a physician.

Initial Here*I understand that it is extremely important to strictly follow all homecare regimen instructions when striving for optimal results.

Initial Here*I understand that if I experience any adverse side effects that appear to be attributable to my use of homecare regimen products, I would discontinue use of the product and notify the office

Authorization. I hereby authorize Camellia Alise, LLC, its employees, and agents to perform skincare treatments. I fully understand these treatments may have limited applications. I am aware that the practice of therapeutic skincare is not an exact science, and I acknowledge reputable practitioners cannot properly guarantee quality and/or results or freedom from complications, and I have not received such guarantees. I acknowledge I have had the opportunity to ask questions, and I fully understand the treatments I am about to receive.
I understand that I am responsible for all costs of the treatments.

I hereby certify I do not have any of the foregoing conditions, devices or implants as described above. Initials *

WAIVER AND RELEASE OF LIABILITY RIGHTS.

READ THE ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING.

1. RELEASE OF LIABILITY – To the maximum extent allowed by law, I, the undersigned (“I”), agree to waive and release any and all claims, suits or related causes of action against Camellia Alise, LLC, its owners, officers, employees, or agents (collectively “Camellia Alise, LLC”), for negligence, injury, loss, death, costs, or other damages to me, my heirs or assigns, while on the premises where Camellia Alise, LLC will be performing my procedure.

2. ASSUMPTION OF RISK – I understand and acknowledge there are risks involved with spa services and treatments. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive Camellia Alise'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 Camellia Alise's liability if such results or complications occur. In consideration for Camellia Alise's 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 and/or my family while undergoing this procedure or side effects that may be experienced after the procedure is performed. I understand that the service providers do not diagnose illness, disease, or any other physical or mental conditions. The providers also do not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal adjustments. Spa services are not a substitute for medical examinations and diagnosis. It is recommended that I see a physician for any physical or mental ailment that I might have. Any sexual misconduct exhibited by the Client will result in immediate termination of the session, and the client will be liable for payment of the scheduled appointment. If for any reason I am uncomfortable, I may ask the practitioner to cease the procedure and the practitioner will end the session. If I cancel, reschedule, or skip an appointment without 24 hours notice, I agree to forfeit the full session fee.

3. INDEMNIFICATION – I agree I will indemnify, defend and hold Camellia Alise harmless, to the maximum extent allowed by law, from negligence, injury, loss, death, costs or other damages to me, my heirs or assigns, or third parties for claims, suits, or related causes of action asserted against Camellia Alise arising from my conduct and/or my family’s conduct while on the premises or participating in any off-site activity in conjuction with Camellia Alise.

4. APPLICATION – I agree that this Waiver and Release of Liability (“Release”) shall apply to each visit I make to Camellia Alise including future visits, regardless of the date that this form is signed below.

5. AGREEMENT TO COMPLY WITH RULES – I agree to, and will comply with, Camellia Alise'sPolicies as posted at www.camelliaalise.com and, I acknowledge Camellia Alise's Policies are subject to change at the sole discretion of Camellia Alise's management.

6. BINDING ON OTHERS – This Release shall bind the members of my family and my spouse or registered 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 Camellia Alise.

7. SEVERABILITY – I agree that the purpose of this Release is that it shall be an enforceable release of liability and indemnity as broad and inclusive as is permitted by Texas law. I agree that if any portion or provision of this Release is found to be
invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid portion will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the Release.

8. APPLICABLE LAW, FORUM & ATTORNEY’S FEES – This Release is governed by and shall be construed in accordance with the laws of the state of Texas, without any reference to its choice of law rules. I agree that any dispute arising from this Release or in any way associated with Camellia Alise shall be brought only in the Superior Court of Harris County, Texas, or in the U.S. District Court for Texas, and I agree to the jurisdiction and venue of those courts for any such dispute. In any litigation in which the validity or enforceability of this Release is contested, I agree that the substantially prevailing party will be entitled to receive all attorney’s fees and costs from the party contesting the validity of this Release.

9. INTEGRATION – This document encompasses the entire agreement of the parties, and supersedes all previous understandings and agreements between the parties, whether oral or written. I acknowledge that no oral representations, statements or other inducements to sign this Release have been made apart from what is contained in this document.

I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure described above. I have fully informed myself of the contents of this release by reading it before signing it. By my signature below I understand and agree to the above terms and conditions.

All of the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting my practitioner to any physical or mental condition which would affect my service or results. I am aware of and will inform my practitioner(s) of any changes in my health. I understand that these services do not constitute as medical treatment.

MAXIMUM LIABILITY. CAMELLIA ALISE’S MAXIMUM AGGREGATE LIABILITY TO PATIENT RELATED TO OR IN CONNECTION WITH THE PROCEDURE PERFORMED BY CAMELLIA ALISE, ITS EMPLOYEES, OR AGENTS WILL BE LIMITED TO THE TOTAL AMOUNT PAID TO CAMELLIA ALISE BY PATIENT FOR THE PROCEDURE DESCRIBED IN THIS AUTHORIZATION AND CONSENT.

Do you authorize Camellia Alise, LLC and its representatives to photograph or record you for educational, promotional, advertising, publication, or trade purposes, and release the company from any related claims or liability?*

YesNo

If you do not authorize promotional use, do you understand that photos may still be taken solely for your medical history and progress tracking?*

Yes, I understand

I have fully informed myself of the contents of the release by reading it before signing it. By signing below, I understand and agree to the terms and conditions provided.

Client Signature*

Date*

Camellia Alise Representative

Date

IF GUEST IS A MINOR, SIGNATURE OF PARENT OR RESPONSIBLE ADULT IS REQUIRED BELOW:

Parent/Guardian Signature

Date

SKINCARE INTAKE FORM