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FACIAL INTAKE FORM

FACIAL INTAKE FORM

Please fill out this initial intake form for us to better assess you.
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    We need a current mailing address as we could ship you products in the future.
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    Please tell us about the products you use during the Day and Night. Any regimen or routines to disclose.
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    At work, you may not notice everything you do to your skin. Are you a face grabber? Touch your face while stressed? Work in a environmental stressor workplace?
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    Whether it is THC or Tobacco. Let us know how often.
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    I hereby consent to and authorize The Obsidian Spa to perform any of the following treatments: Facials, Peels, Waxing, Body treatments, and other Esthetics Services.


    Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications of this treatment. 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 have read and understand the post-treatment home care instructions. 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 the practitioner immediately. 


    I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically. 


    I understand that my data will be strictly confidential. The Obsidian Spa does not sell, share, or resell information.I have read and fully understand this agreement and all information detailed above. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment), whose signature appears below, 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. I also release The Obsidian Spa of any liability that may arise from this procedure.

     

    I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, The Obsidian Spa will not be liable.

     

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    I consent to photographs being taken before, during and after each procedure. I agree to these photos being stored electronically in my case file and will be used only for educational or promotional purposes.
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