Facial Treatment Consent Form

Your treatment may include the following: enzyme peels, extractions, dermaplaning, high frequency, LED light therapy, oxygen therapy and other treatment modalities as necessary.

General Information

First name

Last name

Address

Date of Birth

Occupation

If referred, by who?

Phone

Would you like to recieve texts as form of communication regarding your appointments, appointment reminders etc.? Required

Yes

Medical History

If you selected 'other' for either question above please describe below:

List any medications (oral & topical) and supplements you are currently taking:

Please list any surgeries, including plastic surgery:

Have you ever recieved any botox or fillers? If so, where and when?

Have you ever recieved any advanced cosmetic procedures such as: chemical peel, IPL Photofacial, Laser Hair Removal, Microdermabrasion or Micro-Needling? If so, when? Please specify below:

Are you or have you been on Accutane within the past 6 months? Required

Yes

Have you used Retin-A, Renova, AHA or Retinol derivative products within the last 7 days? Required

Yes

Have you ever been diagnosed with eczema, psoriasis or rosacea? Required

Eczema

Psoriasis

Rosacea

None of the above

Are you claustrophobic? Required

Yes

Female Clients

Are you taking birth control?

Yes

Are you pregnant or breast-feeding? Required

Yes

Your Skin

What would you say your skin type is? Required

Normal (no visible blemishes, fine pores, smooth texture)

Acneic (cystic or nodules)

Sensitive (reactive to fragrances, often irritated)

Dry (dull, visible lines, feels tight, dry patches)

Oily (enlarged pores, excessive oil)

Combination (oily and dry patches, oily t-zone, hormonal breakouts)

When you go out into the sun do you (check one) Required

Always use SPF

Sometimes use SPF

Never use SPF

Please list your skincare products checked above (Name/Brand)

Have you recieved any of these facial hair removal services in the last 7 days? Required

Waxing/Sugaring

Threading

Laser/Electrolysis

None of the above

How many ounces of water do you drink daily? Required

More than 80oz

About 80oz

Less than 80oz

What are your favorite hobbies?

Please read ALL of the following statements carefully and indicate your understanding and acceptance:

I understand that my facial treatment may include clinical-strength products, enzymes, dermaplaning, extractions, high frequency, LED light therapy, oxygen therapy and other treatment modalities as necessary.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity and treatment received.

I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, multiple treatments are necessary and I need to follow the maintenance home protocol. I understand that treatments results will vary from person to person.

I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.

I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness, tightness, or cooling sensations.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact a member of Amore Hair Salon + Spa.

I acknowledge that if I fail to use a minimal sunscreen (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm for at least 48 hours after treatment.

I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Retin-A (retinol) or any contraindicated topical ingredients/products should be discontinued five to seven days prior to the treatment with exception of Accutane which must be discontinued for 6-12 months prior.

I have not received cosmetic injectables such as Botox or Dermal fillers ( or any cosmetic injectables ) within the past 2 weeks. I understand that I must wait at least 2 full weeks before any facial treatment can be performed.

I have not had a peel treatment of any kind within 14 days of my treatment at Amore Hair Salon + Spa. I understand I cannot have another treatment until recommended by a licensed professional at Amore Hair Salon + Spa. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by the Amore Hair Salon + Spa staff.

PHOTOGRAPHS: I give permission for photographs to be used by the Amore Hair Salon + Spa staff for monitoring my treatment progress.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Amore Hair Salon + Spa of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I do not currently have, nor have experienced symptoms such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, runny nose, sinus congestion, nausea or vomiting, diarrhea, or new loss of taste or smell within the past 14 days.

A. CANCELLATION POLICY

We require 24 hour advance notice in order to cancel or reschedule any service with no charge. If your appointment is not cancelled within this notification period, your appointment is considered confirmed. Any appointment cancelled, or changed without 24 hour notice will result in a charge equal to 20% of the reserved service amount. “NO SHOWS” will be charged 50% of the reserved service amount. Because of this policy, a valid credit card number is required at time of booking. This policy also applies to gift card and certificate holders. We understand that certain circumstances may prevent you from being able to make your appointment and will do our best to work with you in that situation.

B. LIABILITY

I will let my Esthetician/Skin Therapist know if anything changes between appointments that could affect my service, (such as new medications, new topical creams & exfoliation, surgeries, botox/fillers, etc.).
I will follow all written and oral aftercare instructions given by my Esthetician/Skin Therapist to ensure I obtain the best results on each service I receive.

C. WAIVER, RELEASE, ASSUMPTION OF RISK

While Amore Hair Salon + Spa LLC and its staff take reasonable precautions to minimize the likelihood of any personal injury resulting from the provision of skincare treatment services, there is inherent risk involved in the delivery and receipt of skincare treatment services, which risk cannot be completely eliminated. By signing below, I acknowledge the existence of this risk, and I agree to accept and assume this risk. I further acknowledge that it is my responsibility to ask questions about the services, to disclose all known allergies and medical conditions to the service provider, and to make an informed decision regarding the receipt of services, all prior to receipt of any services.

TO THE MAXIMUM EXTENT ALLOWABLE BY LAW, I HEREBY WAIVE MY RIGHT TO PURSUE ANY CLAIM, ACTION, OR DEMAND AGAINST AMORE HAIR SALON + SPA LLC, ITS EMPLOYEES, AND ITS STAFF, RELATING IN ANY MANNER TO THE RECEIPT OF SKINCARE TREATMENT SERVICES. I FURTHER RELEASE AMORE HAIR SALON + SPA LLC, ITS EMPLOYEES, AND ITS STAFF FROM ANY AND ALL LIABILITY FOR CLAIMS RELATING TO MY RECEIPT OF SKINCARE TREATMENT SERVICES. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, LOSSES WHICH MAY OCCUR AS A RESULT OF: ALLERGIC REACTIONS; SKIN IRRITATION OR DRYNESS; POST-TREATMENT AILMENTS; AND EQUIPMENT MALFUNCTION.

By my electronic signature below, I give consent to receive treatments at Amore Hair Salon + Spa LLC and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or Amore Hair Salon + Spa LLC for any services rendered.

By signing below, I agree to the cancellation policy and waiver/release described above. I am aware there are no refunds on any service or product. I agree that this document constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. (If client is under 18 years old, parent/guardian must sign below.)

Your Signature

Today's date

The Salon

The Salon

The Salon

Facial Treatment Consent Form

General Information

Medical History

Female Clients

Your Skin