Client Information and Medical History

Client Name First Name   Last Name   

Date of Birth      

Email Address   Email   

Home Address   Street Address      City   State   Zip   
  
Phone Number   Area Code   Phone Number 

Emergency Contact & Information   First Name   Last Name   Area Code   Phone Number 
  
How were you referred to us?

I hereby consent to and authorize Saucy Esthetics to perform the following treatment.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.

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

I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment
care, I will consult my skincare professional immediately.

I have also, to the best of my knowledge, 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 also will give consent for Saucy Esthetics to take Before and After Photos for Insurance Purposes.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, Saucy Esthetics responsible for any of my conditions
that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.