Forms and Waivers

Covid-19 Information and Liability Waiver
Waxing Information and Consent Form
Lash and Brown Information and Consent Form
Microdermabrasion Information

COVID-19 Information & Liability Waiver

First Name

Last Name

COVID-19 Information

1. Have you had a fever in the last 24 hours of 100°F or above?

YES

2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

YES

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

YES

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

Consent for Treatment
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

Client Signature

Parent or Guardian Signature (in case of a minor):

COVID

Waxing

Client Information and Consent—Waxing

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?

YES

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?

YES

Are you using any other skin thinning products and/or drugs?

YES

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

YES

Do you use a tanning bed?

YES

Are you diabetic?

YES

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):

What skin products do you regularly use on your skin?

Have you ever been treated for cancer? If yes, when and what types of therapies were used?

Please list any other illness/condition you are currently being treated for by a medical professional

(Female clients) When is your next menstrual cycle due to begin?

(Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. 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 esthetician immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, 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.

Client Name (printed)

Client Name (signature)

Todays Date

Thank You! Click here to download Copy of Waxing Consent Form

Lash and Brow

Client and Consent: Lash and Brow Tinting

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Have you ever used hair color before?

YES

Have you ever had an allergic reaction to hair color?

YES

Do you wear contacts?

YES

What over-the-counter or prescription skin care products are you currently using?

Do you have diabetes, lupus, or any auto-immune disease?

YES

If yes, describe

Please list any illnesses or conditions you are being treated by a physician for:

Please list any medications you are taking, including over-the-counter herbs, vitamins and supplements:

List any allergies you have:

Have you ever had your brows or lashes tinted?

YES

If you had an adverse reaction to a previous tinting, please explain:

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below. By Checking the boxes below you understand the following statements:

I understand that tinting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the tint enter into the eye.

I understand that if the tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.

I understand that some irritation, itching or burning may occur to the skin which comes in contact with the tinting agent.

I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.

I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wanted.

I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks.

I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the tinting procedure we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, 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.

Client Name (printed)

Client Name (signature)

Todays Date

Thank You! Click here to download Copy of Lash and Brow Consent Form

Microdermabrasion

Microdermabrasion Information Sheet

First Name

Last Name

By checking the boxes below you understand the following statements:

What is Microdermabrasion?

Microdermabrasion uses an adjustable applicator head that removes dead surface skin cells and initiates cellular turnover at the dermis and epidermis levels in a safe controlled manner. This approach respects the integrity of the skin and promotes even healing. Maintaining even cellular growth on the surface aids in the youthfulness of the skin’s appearance.

Microdermabrasion has been used to treat aging and sun-damaged skin, some types of acne and acne scarring, altered pigmentation, fine lines and wrinkles, and stretch marks. Results may include improved skin tone, fewer breakouts, diminished appearance of scars, even skin color, refined skin pores, renewed elasticity, and a healthy glow.

What should you expect during your treatment?

Prior to your first microdermabrasion, as your esthetician, I will perform a thorough skin analysis. If microdermabrasion is not appropriate, you are informed during this session and an alternative treatment may be recommended instead. If microdermabrasion is for you, maximum results are obtained by participating in a series of treatments plus following a home care regimen.

To further enhance your outcome, I require that you use products specifically directed toward obtaining correction. Your current daily regimen and skin care projects used will be reviewed, and you will be instructed which products you should continue to use, and will be advised on any recommended additions to your regimen. I recommend keeping regular appointments and carefully following your home care regimen to support your results.

As your esthetician, I take every precaution to ensure that your skin is well hydrated and calm prior to leaving each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always check with me if you have any concerns after the treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.

After your treatment, sunblock must be worn at all times and tanning beds should never be used. You are making an investment in your face: therefore, it is to your benefit to continue to protect it long after your series is completed.

Is satisfaction guaranteed?

The majority of my clients receive satisfactory to above average results with a series of treatments. Maximum results are highly dependent on your age, cumulative sun exposure, health, menopause, lifestyle, genetic traits, general skin condition, and your willingness to follow recommended protocols.

Be aware that many changes may occur deeper within the skin over time. I find that when participating in a series of treatments, along with a commitment to your daily skin care regimen, noticeable differences may indeed be the outcome. You may see a reduction of fine lines and a softening of deeper wrinkles, reduction of discoloration, softening and possible reduction
in scars, and an overall improvement to the skin’s tone and appearance. To continue the maintenance of your skin after you complete your treatment(s), I may inform you of long-term age management programs.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for microdermabrasion treatment and must be disclosed prior to treatment.

Active infection of any type, such as Herpes simplex virus or flat warts.
Active acne
Sunburn
Recent use of topical agents such as glycolic acids, alphahydroxy acids and Retin-A
Any recent chemical peel procedure
Uncontrolled diabetes
Eczema, dermatitis
Skin cancer
Vascular lesions
Oral blood thinner medications
Rosacea
Tattoos (not effective)
Pregnancy
Use of Acutane within the last year
Family history of hypertrophic scarring or keloid formation
Telangiectasia/erythema may be worsened or brought out by skin exfoliation

Post-Treatment/Home Care

Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided.

Direct sunlight exposure is to be completely avoided immediately following the treatment
(including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with an SPF of 30 or greater. Although sunscreen should be a part of your daily skin care, for a minimum of two weeks, a sunscreen with at least a SPF of 15 must be applied.

Cleanse your face with water or a mild soap substitute, twice daily followed by a mild sunscreen such as (minimum SPF 30). If a site other than the face is treated, you only need to cleanse once daily, followed by sunscreen.

In the event that you may have additional questions or concerns regarding your treatment or suggested home product / post-treatment care, you must consult your therapist immediately.

Client Name (printed)

Todays Date

Client Name (signature)

Thank You! Click here to download copy of microdermabrasion form

COVID-19 SAFTEY POLICY AND WAIVER

Forms and Waivers

COVID-19 Information & Liability Waiver

Client Information and Consent—Waxing

Client and Consent: Lash and Brow Tinting

Microdermabrasion Information Sheet

What is Microdermabrasion?

What should you expect during your treatment?

Is satisfaction guaranteed?

Contraindications

Post-Treatment/Home Care