The following information is essential to optimize the results of your service: Which concerns apply to your skin? Please check all that apply:
Please check the prescription medications you are currently using:
Please take a moment to carefully read the following list of skin conditions and check any that have affected your health either recently or in the past:

All the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting my Esthetician any physical or mental condition which would affect my service or results. I understand my treatment is therapeutic in nature and will alert my Esthetician to any discomfort.


I understand and acknowledge there are risk involved with the treatment of facials, body treatments, chemical peels and dermaplaning. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive the Esthetician’s liability if such results or complications, or effects and hereby waive the Esthetician’s liability is such results or complications occur. In consideration for the Esthetician preforming this procedure, I agree I will
assume the risk and full responsibility for 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 is performed. I understand that the Esthetician does not diagnose illness, disease, 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 payment of the scheduled appointment. To the maximum extent of the law, I agree to waive and release any and all presents and future claims, suits or related causes of action against the Esthetician, service providers, owners, officer, employees, or agents for negligence, injury, loss, death costs or other injuries or damages to me as a result of this procedure. I agree this waiver and release shall 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 Covenant” not to sue the Esthetician or any of the services.

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