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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

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

Medical History

Have you experienced any of these health conditions in the past or present?
Any Known Allergies?
Are you or have you been on Accutane within the past 6 months?
Have you used Retin-A, Renova, AHA or Retinol derivative products within the last 7 days?
Have you ever been diagnosed with eczema, psoriasis or rosacea?
Are you claustrophobic?

Female Clients

Are you taking birth control?
Are you pregnant or breast-feeding?

Your Skin

What areas of concern do you have regarding your skin?
What would you say your skin type is?
When you go out into the sun do you (check one)
When you go out into the sun do you (check one)
What skincare products do you use on a daily basis?
Are you currently using any products that contain:
Have you recieved any of these facial hair removal services in the last 7 days?
Do you?
How many ounces of water do you drink daily?
When it comes to exercise, are you?

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

​​​​​​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.)

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