FACIAL CONSENT

FACIAL AND WAX CONSENT
ELEMENT NINE DAY SPA
CLIENT NAME*
CONTACT NUMBER*
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BIRTH DATE*

MonthDayYear
HOW DID YOU HEAR ABOUT EN?
ANY ALLERGIES?
WHAT ARE YOU HOPING TO ACHIEVE FROM YOUR FACIAL? WHAT ARE YOUR #SKINGOALS?
*OPTIONAL* SEND ANY PHOTOS OF YOUR SKIN YOU WOULD LIKE ME TO SEE BEFORE YOUR APPOINTMENT.
DO YOU GIVE PERMISSION FOR PICTURES AND VIDEOS FOR THE PURPOSE OF DOCUMENTATION POTENTIAL ADVERTISING AND PROMOTIONAL PURPOSES? Y N
HAVE YOU HAD A FACIAL TREATMENT BEFORE? IF "YES". HAVE YOU EVER EXPERIENCED ANY ADVERSE REACTIONS?
IF EXTRACTIONS ARE RECOMMENDED IN YOUR TREATMENT TODAY ARE YOU OK WITH THIS BEING DONE?
WHAT SKIN CARE PRODUCTS ARE YOU USING ?
NORMALOILYSENSITIVEACNECOMBINATION
HAVE YOU HAD ANY MEDICAL PROBLEMS WITHIN THE PAST YEAR? PLEASE ADVISE
ARE YOU TAKING ANY MEDICATIONS I SHOULD BE AWARE OF?
FEMALE CLIENTS
ARE YOU PREGNANT OR TRYING TO BE PREGNANT?
ARE YOU NURSING OR LACTATING?
WAXING CONSENT
WHICH WAX SERVICE ARE YOU GETTING TODAY?
ANY SKIN CONCERNS YOUR ESTHI SHOULD BE MADE AWARE OF?
HAVE YOU HAD ANY ADVERSE REACTIONS OR ALLERGIES? PLEASE ADVISE
ARE YOU CURRENTLY TAKING ANY MEDICATION THAT MAY BE A CONTRAINDICATION TO WAXING? PLEASE ADVISE
CONSENT
YOUR SATISFACTION AND SAFETY IS OUR NUMBER ONE PRIORITY TO ENSURE YOUR WELLBEING BEFORE DURING AND AFTER YOUR FACIAL AND WAXING TREATMENT PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND POSSIBLE RISKS AND MARK BELOW.

I HAVE CITED ALL CONDITIONS AND CIRCUMSTANCES REGARDING MY HEALTH HISTORY,

Including medications being taken. and any past reactions to products or medications that could prohibit or compromise this treatment.

I UNDERSTAND THAT ADDITIONAL CONDITIONS COULD OCCUR WHICH COULD AFFECT MY ABILITY TO TOLERATE THIS TREATMENT

I further understand there are risks associated In rare cases. irritation and discomfort may occur. I further understand there are risks associated facial treatments. I acknowledge that my skin might experience temporary irritation tightness. redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

ACKNOWLEDGE THAT IF I FAIL TO USE A MINIMAL SPF SUNSCREEN (SPF30), I AM MORE SUSCEPTIBLE TO SUNBURN, SKIN DAMAGE AND HYPER PIGMENTATION

I UNDERSTAND THAT AFTERCARE NEEDS TO BE FOLLOWED

I understand this is most important in order to see improvements
- CONSENT TO THE BEST OF MY KNOWLEDGE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT MAY BE RELEVANT TO MY TREATMENT
I release Element Nine any liability associated with any injuries and/or current and future conditions resulting from this facial treatment

You hereby acknowledge and confirm that you are or have been fully informed to the nature of the service you have requested and are aware with all risks associated. You informed your technician of an pre-existing conditions, allergies or product sensitivities that may have an impact on treatment. We are not liable for any dissatifaction, discomfort, damage, loss or injury you may incur arising directly or indirectly out of any services provided or any product used. Complimentary services or treatments are only offered on the express understanding that the service offered is not and may not be deemed as an admission of liability or fault and are also subject to the conditions of this agreement.
Signature

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APPOINTMENT DATE

MonthDayYear
Should be Empty:

FACIAL AND WAX CONSENT

ELEMENT NINE DAY SPA

FEMALE CLIENTS

WAXING CONSENT

CONSENT

- CONSENT TO THE BEST OF MY KNOWLEDGE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT MAY BE RELEVANT TO MY TREATMENT