Facial Consent Form

Client Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Upload a copy of your Photo ID/Driver's License/Passport

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship to Client*

Appointment Date*

Date

Contraindications/Disqualification List

Please review the below to its entirety:

Have any open wounds, lesions or injury
Skin Cancer or Lesions
Pregnant, nursing, trying OR harvesting eggs (No exceptions)
Has Vascular diseases or Cardiac abnormalities; Pace Maker/Defibrulator (Dr. clearance required written/emailed note)
Has had shingles on your face (this can exacerbate a flare up)
Active cold sore breakouts (ALL clients must be on anti-viral/L-Lysine OTC prior to the treatment)
Currently on Accutane or other prescription acne medication (must wait 1 year after last use)
Currently using Retinols (must discountinue retinols for 3-5 days prior to your facial. Retinols can increase sensitivity)
Currently using Hydrocortisone
Currently using Glycolic Acid
Received a facial wax in the last 7 days pre/post treatment
Currently going through chemo, radiation or on oral cancer medications (wait minimum 6 months from last dosage/treatment)
Ocular Herpes-Herpes of the eyes (NO EXCEPTIONS)
Blood dyscrasias/hemophilia-Bleeding disorders (on anticoagulant therapy)
Organ Transplants (Dr. clearance required with written/email note)
If you are receiving Botox or fillers in the facial area on a regular basis, it is best to wait a minimum of 4-6 weeks after to proceed with the procedure. Going into an area that was treated with Botox or fillers too soon can or may cause unwanted diffusion
Diabetes (Dr. clearance required with written/email note)

How to Prepare for your Facial Appointment

Come to your appointment with a bare, clean face; no makeup, toner or moisturizer
Please avoid:
- Using Glycolic Acid 24 hours before your facial
- Using Retinol products 3-5 days before your facial
- Using hydrocortisone
- Facial waxing 7 days before/after your facial

Things to Know

The treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of the skin
Your participation in your skincare treatments will determine the outcome. It is important that you adhere to the home care products your esthetician has recommended
Precise results are not guaranteed, expressed or implied
Depending on the peel performed and your skin quality, the following reactions may occur:
- Prolonged redness, irritation and flakiness
- Dryness and sensitivity
- Severe and allergic reactions in rare instances
If you are receiving a peel, it is impossible to determine how much peeling will occur

What to Expect After Treatment

Please be prepared to:
- Avoid picking, peeling or scratching your skin during the healing phase
- Experience temporary purging 4-6 weeks after your facial
  - It is normal to experience purging because your skin cells need to regenerate and this is how your pores clear itself out. As the surface layer of the skin is shed more quickly after a facial, excess sebum, flakes, buildup of clogged pores will rise to the top to push everything to the surface
- Experience crusting or shedding of the skin depending on the facial treatment provided (Ex: Chemical Peel)
- Avoid direct sun exposure for 2 weeks
- If you are receiving a chemical peel, flaking begins within 48 hours. It's impossible to pre-determine how much peeling will occur. The shedding will usually subside within 5-7 days

How to Care for Your Skin After Treatment

Avoid picking, squeezing or touching the treatment area
Avoid wearing makeup for 6-12 hours
Do not have any other facial skincare treatments for 48 hours
Avoid sunbathing or sunbeds for 48 hours
Avoid swimming, saunas, steam and hot showers for 48 hours
Take lukewarm showers
If any redness or irritation occurs, apply a cold towel to the area
If any symptoms persist, please don't hesitate to reach out

Reminder

Pre-scheduling routine facials & maintaining your recommended skin care regimen will help you maintain your skin

By signing the field below I acknowledge that I have read the Contraindications/Disqualification List, How to Prepare for Your Appointment, What to Expect and Aftercare. I understand that the result of the procedure is permanent which may vary depending on numerous factors due to the nature and pathology of my skin.

Client Signature*

Client Signature Date*

Date

Upload a clear photo of the procedure/treatment area in natural lighting

Do you have any of the following conditions?*

Rows	Yes	No
Tuberculosis
Herpes
Epilepsy
Hepatitis
Blood Thinners
Eczema/Psoriasis
Pregnant/Nursing
Scarring/Keloiding
Latex Allergies
Bruise, swell, bleed easily
Have glaucoma or any other eye disease
Had Lasik eye surgery
Wear makeup daily
Laminate/Tint your eyebrows
HIV
Diabetes
Asthma
Skin Conditions
Hemophilia
Cardiac Valve Disease
Fainting/Dizziness/Epilepsy
Gonorrhea
MRSA/Staph Infections
Antibiotic Allergies
High Blood Pressure
Had eye trauma
Have had vision correction procedures
Plan to have lasik eye surgery
Thread or wax your eyebrows
You are tanned in the procedure area
Have nerve damage to the procedural area
Currently taking aspirin
Use illegal drugs
Wear sunscreen daily
Use Glycolic Acid or Vitamin C
Have had botox or fillers
Have a history of medication use
Prior to dental procedures (periodic or surgical), have you had or require antibiotic therapy?
Have taken Accutane, Retin-A, Renova, Differin, Tazorac, Benzoyl Peroxide or other oral/topical acne medications within the last year
Currently taking steroids
Plan to/have scheduled any future facial surgeries
Currently taking anti-inflammatory medications
Do you wear contact lenses?
Do you currently have a sunburn, windburn, acne flareup or skin irritation?
Have had cold sores or fever blisters
Have a pacemaker, metal implant, defibrillator
Currently taking Antibiotics
Allergic to Aspirin

If you have ever received a chemical peel, please state when.

Are you currently taking medication? If yes, please list the medication name and provide the date you last took the medication.*

Do you have any allergies to cosmetic makeup, skincare products, soaps, shampoos? If yes, list the brand and type of reaction:*

Have you had any facial cosmetic surgeries? If yes, please describe what type and when:*

Do you plan or have scheduled any Botox treatments? If yes, when?*

Please list all skincare products you are currently using

By initialing below I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining facial treatments from Danicca Prom (hereafter called “Technician”) and Glow Beaute that all of my questions have been answered to my full and total satisfaction.

I have completed this form to the best of my ability and knowledge and agree to inform my technician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and "Glow Beaute" for any injury or damages incurred due to my misrepresentation of my health history.

Signature

Signature Date

Date

I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:

I am not pregnant or nursing. I do not have any history of herpes infection at this proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood.*

Initial Above

I give permission to "Glow Beaute/Danicca Prom" to perform facial treatments on me.*

Initial Above

I understand that there is no guarantee to me as to the condition of my skin or degree of improvement expected following treatment.*

Initial Above

I understand that multiple treatments, routine facials and the use of the recommended home skin care maintenance are required to achieve optimal results.*

Initial Above

I have received pre and post care instructions and I will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my result.*

Initial Above

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as direct or indirect result of my decision to have a facial treatment at this time.*

Initial Above

I acknowledge and give consent to this Glow Beaute to use images of my treatment area(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed and or television etc.*

Initial Above

I agree to release and forever discharge, and hold harmless, the esthetician, all employees, contractors and the management from any and all claims of negligence, damages, or legal actions arising from my facial and assume all responsibility for the decision(s) made consenting to this treatment.*

Initial Above

I understand this treatment can not be performed if I have any of the following: infection, skin disorder, open cuts or wounds, abrasions, anxiety issues, epilepsy, pregnant, sunburn, windburn, chapped skin or an active fever blister outbreak.*

Initial Above

I accept FULL RESPONSIBILITY for any complications that may arise during or after the procedure and service provided, which is being performed at my request and approval.*

Initial Above

I agree that I have not used Accutane during the last 12 months.*

Initial Above

I have read and understand the cancellation policy of the service provider and agree to abide by the above conditions.

Client Signature*

Client Signature Date*

Date

1. Services to be Provided: This office is providing facial treatments.*

Initial Above

2. Payment: A non refundable booking fee is required to secure your appointment prior to the service. The deposit is applied to the service grand total and the remaining balance is to be paid at the end of the service performed.*

Initial Above

3. Client Cooperation: This Agreement contemplates full Client cooperation in the course of services agreed upon. Our office policy requires 72-hour advance notice for appointment cancellation. Failure to do so may result in additional service charges to be added during next appointment.*

Initial Above

4. Termination: Subject to the provisions of paragraphs 5 and 6 of this Agreement, the Client may discontinue care and terminate this Agreement at any time by written notice to that effect delivered in person, or by mail, to the office. Such “notice of termination” shall discharge the office from all further obligations and/or duty to render care to the client. The office reserves the right to terminate this Agreement in its sole discretion notwithstanding any other terms or provisions of this Agreement.*

Initial Above

5. No Refunds: To encourage commitment and follow-through, the service provider offers no refunds. No refunds will be made on any services or treatments. There will be no exceptions. *

Initial Above

6. Release of Liability: Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company's behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company's gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind.*

Initial Above

7. Complete Agreement: This Agreement constitutes the complete agreement and understanding between Client and Office and will not be changed or modified in any way unless agreed to by both parties in writing.*

8. Reschedule/Cancelations: We require 72-hour advance notice to reschedule/cancel an appointment. One reschedule is allowed free of charge. All future rescheduled appointment require a brand new booking fee. Pre-payment in full is required to reschedule after 3 reschedules or more.*

THE CLIENT HAS FULLY READ THIS AGREEMENT AND ANY SUPPLEMENT HERETO, AND UNDERSTANDS AND AGREES TO ABIDE BY ALL OF THE TERMS HEREOF.

Client Name*

First NameLast Name

Client Signature*

Client Signature Date*

Date

Please state whether you've experienced/are experiencing the following*

Rows	Yes	No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest

YesNo

ONLY IF YOU ANSWERED YES ABOVE Contact tracing will be conducted for close contacts (any individual within 6 feet of an infected person for at least 15 minutes) of laboratory-confirmed or probable COVID-19 patients. Testing is recommended for all close contacts of confirmed or probable COVID-19 patients.Asymptomatic contacts testing negative should self-quarantine for 14 days from their last exposure (i.e., close encounter with confirmed or probable COVID-19 case) If you have already been tested negative after being in contact with someone positive, please provide your test results below

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Glow Beaute has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Glow Beaute can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by Glow Beaute and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Glow Beaute harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Glow Beaute. I understand that this release discharges Glow Beaute from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Glow Beaute. This liability waiver and release extends to the salon together with all owners, partners, and employees.

Client Signature*

Client Signature Date*

Date

Facial Consent Form

CANCELLATION POLICY

Service Agreement

COVID-19 LIABILITY WAIVER