Face Haus Guest Intake Form

Face Haus Guest Intake Form
Guest Name*

First NameLast Name
Appointment Date*

MonthDayYear
The information collected on this form will be used to determine your treatment access and Face Haus’ ability to safely perform services on you. When you are asked to provide personal information, you may decline. However, Face Haus holds the right to refuse service if you choose not to provide or disclose information that is necessary for the health and safety of our employees, lounge members and other guests .
HEALTH AND WELLNESS QUESTIONNAIRE

Are you currently experiencing or have you experienced any of the following in the last 14 days? Please check all that apply:
CoughShortness of breath or difficulty breathChillsRepeated shaking with chillsption 4Muscle painHeadacheSore throatLoss of taste or smellDiarrheaFeeling feverish or a measured temperature greater than or equal to 100.0 degreesKnown close contact with a person who is lab confirmed to have COVID-19None
If you have experienced any of the above within the last 14 days, we will reschedule your appointment for a future date & visit to our lounge. We appreciate your understanding and look forward to serving you soon!
SKINCARE SPECIFIC QUESTIONNAIRE
YesNo
YesNo
YesNo
YesNo
YesNo
Brief Medical History

Please place a mark next to any of the conditions below that are currently applicable and provide additional information if necessary. Each condition indicated may have an effect on how and if Face Haus is able to perform your treatment(s).
YesNo
Please Specify your Allergies?*
ie. Fruits, nuts, vegetable oils
Contagious DiseasesRecent Surgery / Scar TissueAsthmaEpilepsySkin DisordersCancer (Skin, Other)Heart Condition / PacemakerSunburnNoneOther
FACE HAUS, LLC - INFORMED CONSENT
I UNDERSTAND AND AGREE that any services I receive from Face Haus, LLC (“Face Haus”) present risks and hazards, such as unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection and change in skin pigmentation, allergic reaction, muscle damage, increased hair growth and other injury or adverse reactions.

I agree and understand that even though precautions may be taken, not all risks can be known in advance. I understand that response to the services offered at Face Haus varies on an individual basis and that specific results are not guaranteed.

I have stated all my known physical conditions and medications in my Guest Intake Form. I am in good physical condition and have no disability, impairment, or ailment preventing me from receiving the services.

I understand that the service providers at Face Haus do not diagnose illness, disease or any physical or mental disorder, nor do they prescribe medical treatment or drugs. I acknowledge that Face Haus services are not a substitute for medical examination or diagnosis.

I further understand and agree that by using Face Haus's skin health analysis tool, I am also consenting to the collection, storage, and use of my facial skin data by PerfectCorp, a third-party service provider engaged by Face Haus for this purpose. PerfectCorp is bound by contractual obligations to protect the confidentiality and security of my data and is prohibited from sharing it with any other party without my explicit consent. My data will be stored securely for a period of 30 days and will only be used for the purpose of generating my personalized skin report. I have the right to access and delete my data at any time by contacting PerfectCorp directly.

I HEREBY GIVE MY VOLUNTARY INFORMED CONSENT TO AND ASSUME ALL RISKS ASSOCIATED WITH THE PERFORMANCE OF THE SERVICE(S).

By entering my initials I agree to the above terms in this Informed Consent.
Please enter your initials . enter initials*
Date*

MonthDayYear
Should be Empty:

Face Haus Guest Intake Form

HEALTH AND WELLNESS QUESTIONNAIRE

SKINCARE SPECIFIC QUESTIONNAIRE

Brief Medical History

FACE HAUS, LLC - INFORMED CONSENT