Potomac Spa Waiver

Spa Consent Form
Name*

First NameMiddle NameLast Name
Sex*
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever had a facial before?

YesNo
How do you prefer the pressure of your massage?

LightMediumFirm
Are you (or might you be) pregnant?*

YesNo
If yes, how many months pregnant are you?
Do you have drug allergies?*

YesNo
If yes, please list the names of the medications you are allergic to here.
Are you allergic to any of these products?

AspirinSkincare productsCitrusTree nutsSalicylic acidBenzoyl PeroxideLatexOther
Do you have any specific skin concerns or problems? Check all that apply.

RosaceaTendency to Burn EasilyAcne BreakoutsScarsOther
Do you have any of these medical conditions? Check all that apply.

CancerHeart DiseaseEpilepsyVaricose VeinsFluid RetentionHeadachesMetal implantsOsteoporosisOsteoarthritisRheumatoid ArthritisBlood Clotting AbnormalityFibromyalgiaEasy BruisingSkin RashAbscess/Open soresSkin SensitivityHepatitis CHerpes I or IIHIV PositiveInner Ear ProblemThyroid ImbalanceAsthmaChronic Fatigue SyndromeDiabetesOther
Please list any skincare products you currently use.
Are you using any of these skincare products?

Tretinoin (Retin-A)AccutaneRenovaHydroquinoneOther
Have you ever had any of the following treatments?

Chemical PeelLaserMicrodermabrasionSkin resurfacing Treatment
If yes, when was your last treatment?
Have you been under the care of a dermatologist in the last year?

YesNo
If yes, for what condition were you treated?
What are your skincare goals?
Spa Waiver:
- I understand and acknowledge that there are risks associated with facials and peels.
- I have had the opportunity to ask questions about these risks and any potential complications.
- I understand that providing false or misleading information may lead to undesirable results, complications, or effects. I hereby waive Potomac Dermatology and Skincare Center of any liability should such issues occur.
- I understand that failure to follow post-care instructions may result in adverse outcomes, and I waive Potomac Dermatology and Skincare Center’s liability for any resulting complications or effects.
- In consideration of Potomac Dermatology and Skincare Center performing this and any future procedures, I agree to assume full responsibility for any injuries, losses, or damages that may occur during or after treatment.
- I understand that the esthetician does not diagnose illness, disease, or any other physical or mental conditions.
- Any sexual misconduct will result in the immediate termination of the session, and the client will remain responsible for the full cost of the scheduled appointment.
- To the maximum extent allowed by law, I agree to waive and release all current and future claims, suits, or causes of action against Potomac Dermatology and Skincare Center, LLC, its owners, employees, or agents for negligence, injury, loss, death, or any other damages resulting from services provided.
- I agree to this waiver and release and bind the members of my family, and any spouse or domestic partner, if I am alive, as well as my estate, family, heirs, administrators, personal representatives, or assigns if I am deceased, and shall be deemed as a "Release, Waiver, Discharge, and Covenent" not to sue Potomac Dermatology and Skincare Center.
Maximum liability:

Potomac Dermatology and Skincare Center’s maximum aggregate liability to the patient, related to or arising from procedures performed by its employees or agents, is limited to the total amount paid by the patient for the specific procedure described in this authorization and consent.
I have read all of the above information and will discuss pertinent details with my esthetician or lash technician. I understand that this work does not constitute medical treatment; it is a form of health and wellness maintenance. I take full responsibility for alerting my esthetician or technician to any physical conditions that would affect this treatment.
Cancellation Policy and Financial Agreement

We are honored to be a part of your care. As we often have a waiting list of clients seeking appointments, we kindly request that you cancel or reschedule at least 48 hours in advance of your scheduled appointment. To make changes, please contact our office at 703-356-5111 or text us at 703-215-2139. Voicemails are accepted.

Late Cancellations or Missed Appointments
Appointments that are missed or not canceled with at least 48 hours’ notice will incur the following fees:

A fee of $150.00 will be charged to the credit card on file for facial services.
For spa services under $150.00, the full cost of the scheduled service will be charged.

Late Arrivals
Clients who arrive more than 20 minutes late for their scheduled appointment will be asked to reschedule and will be charged the full fee for the originally scheduled service.
Signature of Patient OR Guardian/Parent For Cancellation Policy and Financial Agreement:*

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Date signed*
Is the client under 18 years of age? If so, a parent or legal guardian is required to sign below*

YesNo
** If client is under 18, a parent or legal guardian must sign below to give permission for client to be treated by one of our licensed aestheticians.
Client Name

First NameLast Name
Name of Guardian/Parent Completing this Form (If Applicable)

First NameLast Name
Signature of Patient OR Guardian/Parent

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Spa Consent Form