General Consent Form
Client Name
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First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date Picker Icon
Email
*
example@example.com
Do you have any skin concerns?
Please list any allergies:
Medical History
Are you currently pregnant or nursing?
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Yes
No
Have you have any of the following health concerns? ( Please mark all that apply)
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Not Applicable
Acne
Asthma
Arthritis
Blood clotting disorders
Cancer
Diabetes
Heart disease
Herpes (Cold Sores)
HIV/AIDS
High blood pressure
Skin cancer
Keloid Scarring
Lupus
Other
Other health concerns not listed above:
Current medications:
Are you or have you been on Accutane within the past 6 months?
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Yes
No
Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5-7 days?
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Yes
No
What are your skin care goals?
Please list any skincare products that you are currently using:
Expectations for today's treatment?
Please read ALL of the following statements carefully and indicate your understanding and acceptance:
I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, dermabrasion, dermaplaning, extractions, high frequency, ultrasonic, LED light therapy and other treatment modalities as necessary.
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By checking this box I understand and accept this statement.
I understand that no results are guaranteed due to other variables such as age, skin conditions, sun damage, smoking, climate and routine.
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By checking this box I understand and accept this statement.
I understand that there may be some degree of discomfort, i.e. stinging, hotness, tightness and redness depending on treatments performed. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact a member of the Gorchae Esthetics L.L.C or my primary care physician for severe reactions.
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By checking this box I understand and accept this statement.
I have been candid in revealing any conditions that may have an effect on this procedure as outlined. I will also inform Gorchae Esthetics L.L.C of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.
*
By checking this box I understand and accept this statement.
I do not currently have, nor have experienced symptoms such as cough, shortness of breath or difficulty breathing, fever, chills, shaking with chills, muscle pain, headache, sore throat, runny nose, sinus congestion, nausea or vomiting, diarrhea, or new loss of taste or smell within the past 14 days.
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By checking this box I understand and accept this statement.
I have read and filled out the information above to my best knowledge. If I have any concerns I will address these to my esthetician immediately. I give Gorchae Esthetics L.L.C permission to perform any facial, waxing or brow treatments and will hold her and her staff harmless from any liability that may result from treatments. I also, to my best knowledge, have given an accurate account of my medical history, including all known allergies or prescription drugs or products I'm currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate any negative reaction as much as possible. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when receiving any treatment from the therapist signed below.
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By checking this box I understand and accept this statement.
I knowingly and willingly consent to being serviced by Gorchae Esthetics L.L.C
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By checking this box I understand and accept this statement.
I agree to photographs and/or video images to be taken of me by Gorchae Esthetics L.L.C. I understand the images may be used for purposes of teaching or training or for marketing purposes (website, print, digital or social media).
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Yes
No
Todays date
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Month
-
Day
Year
Date
Signature
*
Submit
Submit
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