Esthetician Services Consent Form And Release of Liability

Esthetician Services Consent Form And Release of Liability
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth*

MonthDayYear
Date
Do you have CareCredit?

YesNo
We are delighted that you have chosen Ben's Beauty Spa (the “Company”) to provide you with certain esthetic and spa services (the “Services”). Such Services should not be performed if you have certain medical conditions. It is your responsibility to inform the esthetician of any pre-existing conditions, limitations, or specific sensitivities that you may have and to inform your esthetician if you feel any discomfort while you receive the Services. If you do experience discomfort, you agree that you will immediately inform your esthetician to adjust the level of pressure. You understand and voluntarily accept any risk associated with the esthetician’s performance of the Services and your use of the Company’s facilities, and hereby release the Company, its directors, officers, shareholders, employees, contractors, agents, and insurers from any and all liability for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you resulting therefrom any such injury or damage resulting from the performance of such Services, my failure to disclose any pre-existing condition, limitation or specific sensitivities, or your failure to inform your esthetician of any discomfort while you receive the Services. Your esthetician may determine that it is unsafe for you to proceed with the Services due to health-related concerns. In this event, you may be required to provide the Company with a physician’s medical release prior to continuing treatment.
Which of the following best describes your skin type:*

NormalCombinationDrySensitiveOilyI'm not sure
Please select the characteristics your skin has:*

Dull/DehydratedRedness/ InflamedBlemishes/AcneLarge PoresLoss of ElasticityBlackheads/ WhiteheadsUneven skin toneSunspots/ Age SpotsOther
What are the main areas you would like to treat?*

Sagging around the jawlineUnder Eye puffiness / darknessWrinkles and fine linesAcneDroopy eyelidsDiscoloration (Sun spots, age spots or hyperpigmentation)Nasolabial Folds (Skin folds that extend from the sides of the nose down to the corners of the mouth)Other
What skin care products do you currently use in the morning?*

Bar SoapEye CreamTonerCleanserMoisturizerExfoliantTonerSunscreenFace OilNone
What skin care products do you currently use in the evening?*

Bar SoapExfoliantEye CreamCleanserSerumsMoisturizerTonerSpot TreatmentNone
Are you using any exfoliating acids?*

NoYes
If yes, please list them below:
How often do you get facials?*

I have never had a facialNot very frequent (once or twice a year)Frequently (Once a month)
Which (if any) Facial Cosmetic Procedures have you done in the past?*

I've never done any Facial Cosmetic ProceduresJUVÉDERM®Sculptra®Other Fillers / InjectablesSurgical Face Lift / Neck Lift / Mini LiftBotoxMicroneedlingOther
If you've had a facial cosmetic procedure, when was it?*

I've never had and facial cosmetic proceduresOver 2 weeks agoA few days agoA year agoOne week agoOver 2 years
General & Medical Information
Are you pregnant?*

NoYes
Have you had surgery recently?*

NoYes
If yes, what procedure was it?
Are you taking any medications?*

NoYes
Are you on Accutane?*

NoYes
Do you have Rosacea?*

NoYes
Are you using Retinoids/Retinols?*

NoYes
If so, which?
How often do you exfoliate?*

NeverOnce a week2-3x a weekOnce a year
Do you use acne medication?*

NoYes
Do you have cancer?*

NoYes
Do you have Fever Blister/ Herpes?*

NoYes
If so, is it active?*

NoYes
Do you have a pacemaker and/or cardiac problems?*

NoYes
Please check if you are affected by any of the following:*

None of the AboveMigrainesMetal Pins or PlatesHepatitisLupusEczemaImmune DisordersHysterectomyUncontrolled DiabetesHigh Blood PressureSkin DiseaseSinus ProblemsEpilepsyAsthmaWartsHIVStrokeArthritisThrombosisPlastic SurgeryOther
Have you ever had an adverse reaction to a cosmetic product?*

NoYes
Are you allergic to any products, cosmetics, food, drugs or ingredients? If so, please list:
I agree that:
- If I experience any pain or discomfort during the Services, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
- I further understand that the Services should not be construed as a substitute for medical examination, diagnosis, or treatment.
- I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such.
- I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the esthetician's part should I fail to do so.
- I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
Also, I understand that:
- The Services offered are not a substitute for medical care, and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in the future.
I, the undersigned, hereby acknowledge that I have read this Esthetician Consent of Services and Release of Liability agreement, and agree to be bound by each and every term and condition contained herein.
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Esthetician Services Consent Form And Release of Liability

General & Medical Information