Client Consent

1
Name
First Name
Last Name
2
Have you received this type of service before??
YESNO
3
Please explain when was the last time you received this type service.
4
Medical HistorySelect all that apply
Diabetes
Lupus
High/Low Blood Pressure
Herpes Simplex
Hyper/Hypo Thyroid
Arthritis
Eczema
Psoriasis
HIV/AIDS
Warts
Epilepsy
Hepatitis
Cancer
Heart Conditions
Metal Implants
Hemophilia
Autoimune Disorder
Abrasions/Cuts
Dermatitis
Hypersensitive Skin
Skin Disease
Sunburn
Other
None
5
Other medical conditions which may affect your service.,
6
If you have a medical condition that may be a contraindication to your service, Please select from one of the options below.
Doctors Note (please submit prior, or bring it with you)
I take full liability
Does not apply
7
Are you pregnant or breastfeeding?
YESNO
8
Are you currently taking any medications? If yes please explain >>>
YESNO
9
Medications
10
Do you have any allergies? If yes, please explain >>>
YESNO
11
Allergies
12
Have you had any major treatments or surgeries done in the past 30 days that may affect your service?If yes, please explain >>>
YESNO
13
Recent Surgery or Treatments
14
Have you received any of the following (w/in the past 2 weeks)Select all that apply.
Botulinum Toxin (Botox, Dysport and Xeomin, etc.)
Collagen Injections
DermaFiller (Juvederm®, Restylane® and Perlane®, etc.)
Other
15
Have you been in the care of a dermatologist within the past 6 months?If yes, please explain
Yes
No
16
ARE YOU CURRENTLY USING RETIN-A, RETINOL, RETINOIDS, AHA/BHA?
Yes
No
17
If yes, please explain the last time you used Retinoid products.*Please note, if you are receiving an advanced treatment today (like microdermabrasion, dermaplaning, waxing, etc.) you need to stop using these ingredients at least 72 hours prior to your appointment.
18
Are you currently or have you recently (3 months) taken ACCUTANE?Also known as Isotretinoin, Zenatane, Absorica, Myorisan, Claravis, and Amnesteem
YESNO
19
I have voluntarily elected to undergo this service.

Although it is impossible to list every potential risk and complication, I have been informed of the most commonly associated risks and contraindications with this service. I have had the opportunity to ask any questions I may have prior to my service. I, therefore, consent to not hold my esthetician or company liable for any issues, damages, or side effects that may occur.

I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle, and that there is a possibility I may require further services in the treated areas to obtain the expected results, at an additional cost.

I have read and understood all available pre and post-treatment care instructions, and acknowledge how medically important it is to follow these instructions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

To the best of my knowledge, I have also 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 assume responsibility, and if I’ve failed to mention anything to my esthetician regarding my medical condition/history - they will not be held liable if any issues, complications, or damages arise. If my medical status changes, I will notify the company prior to my service.

I give consent to take photos of me for the purpose of client records, company education, marketing, and advertising. I also understand my personal information (such as name, email, phone number, etc.) will be held on file by the company. I understand the company may contact me through text, email, and social media for the purpose of business, marketing, and advertising. I understand I have the option to opt-out of any advertising and marketing at any time by doing so electively on those channels.

If I have any questions, I will reach out to the company as soon as possible.
20
CONSENT : I have read and fully understand this agreement and all information detailed above.
Clear
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