Spa Waiver

Spa Registration

SKINKURE
Client 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 PeroxideLatex
Do you have any specific skin concerns or problems? Check all that apply.

RosaceaTendency to Burn EasilyAcne BreakoutsScars
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 SyndromeDiabetes
Please list any skincare products you currently use.
Are you using any of these skincare products?

Tretinoin (Retin-A)AccutaneRenovaHydroquinone
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 there are risks involved with the facials, peels, microdermabrasion, microcurrent, eyelash extensions, tinting, and waxing.
- I have had the opportunity to ask questions regarding these risks and other possible complications.
- I understand that any false or misleading information I have given may lead to undesirable results and complications or effects and hereby waive Skinkure's liability if such results or complications occur.
- I further understand my failure to follow post care instructions may also lead to undesirable results, complications, or effects and hereby waive Skinkure's liability if such results or complications occur.
- In consideration for Skinkure Spa performing this procedure any future procedures, I agree I will assume the risk and full responsibility ofr any and all injuries, losses, or damages which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure or future procedures are performed.
- I understand that the esthetician does not diagnose illness, idsease, or any other physical or mental conditions.
- Any sexual misconduct exhibited by the client will result in immediate termination of the session, and the client will be liable for the scheduled appointment.
- To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits, or related causes of action against Skinkure, LLC, its owners, employees, or agents for negligence, injury, loss, death, costs, or other injuries, or damages to me as a result of this procedure.
- 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 Skinkure spa.
Maximum liability:

Skinkure Spa's maximum aggregate liability to patient related or in connection with the procedures performed by Skinkure, its employees, or agents, will be limited to the total amount paid to Skinkure by the patient for the 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 part of your care. We often have a waiting list of clients who have requested to be seen, so we kindly ask that you adjust or cancel your appointment at least 48 hours before your scheduled appointment time. Contact us at our office for appointment changes at 703-356-5111. Voicemails are accepted.

For appointments that are missed or not cancelled with at least 48-hour notice, the fees are as follows:
• The credit card on file will be charged$150.00 for Facial Services
• For spa services which cost less than $150.00, the credit card on file will be charged the cost of the service only.

***Clients that arrive more than 20 minutes after their scheduled appointment will need to reschedule and will be charged for the service that is scheduled.
Signature of Patient OR Guardian/Parent For Cancellation Policy and Financial Agreement:*

Clear
If you are under 18 a parent or guardian must sign below to give permission for you to be treated by one of our licensed estheticians.
Client Name*

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

First NameLast Name
Signature of Patient OR Guardian/Parent*

Clear
Date signed*
Should be Empty:

Spa Registration