The digital release waiver for beauty industry is easy to use.

Facial Consultation Form and Waiver of Release

Please fill your name: *

Please enter your full name.

Please Enter Date *

Please enter valid date.

Please fill in Address: *

Please enter address.

Phone number: * Please enter your phone number.

Email: * Please enter your email.

Gender: * Please select one here.

Date of Birth: *

Please enter valid date.

What would you like to achieve with your treatment today? * Please enter your answer here.

Have you received a facial treatment before? *

Yes

Please select at least one choice above.

If yes, when? Please enter your answer here.

Which of these best describes your skin type? *

Light/matte complexion - burns moderately, tans gradually

Matte complexion - seldom burns, always tans well.

Brown complexion- rarely burns, deep tans

Black complexion - never burns, deeply pigmented.

Please select at least one choice above.

Do you have any skin concerns or problems pertaining to your face and body? Explain. * Please enter your answer here.

Have you received microdermabrasion, laser, or chemical peel treatments? *

Yes

Please select at least one choice above.

If yes, When? Please enter your answer here.

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *

Yes

Please select at least one choice above.

When? How much? * Please enter your answer here.

Have you used an acne medication? *

Yes

Please select at least one choice above.

If yes, when and what product? * Please enter your answer here.

Please list the products that you use below, type and frequency of use.

Cleanser * Please enter your answer here.

Toner * Please enter your answer here.

Mask * Please enter your answer here.

Eye Product * Please enter your answer here.

Day moisturizer * Please enter your answer here.

Exfoliants * Please enter your answer here.

Scrubs * Please enter your answer here.

SPF * Please enter your answer here.

Night Cream * Please enter your answer here.

Makeup * Please enter your answer here.

Have you used any hair removal methods in the past 6 weeks? *

Yes

Please select at least one choice above.

Where and what method? * Please enter your answer here.

Please check any and all of the following skin conditions that you experience.

Breakouts/acne * Please check it here.

Blackheads/Whiteheads * Please check it here.

Excessive oil/shine * Please check it here.

Rosacea * Please check it here.

Broken capillaries * Please check it here.

Redness/ruddiness * Please check it here.

Sun spot/liver spot/brown spot * Please check it here.

Uneven skin tone * Please check it here.

Sun damage * Please check it here.

Wrinkles/fine lines * Please check it here.

Dull/dry skin * Please check it here.

Flaky skin * Please check it here.

Dehydrated skin * Please check it here.

Eyes

Dehydrated * Please check it here.

Wrinkles * Please check it here.

Puffiness * Please check it here.

Dark Circles * Please check it here.

Do you have allergies to any of the following?

Cosmetics * Please check it here.

Medication * Please check it here.

Food * Please check it here.

Animals * Please check it here.

Sunscreens * Please check it here.

Iodine * Please check it here.

Pollen * Please check it here.

AHAs * Please check it here.

Fragrance * Please check it here.

Shellfish * Please check it here.

Latex * Please check it here.

Do you use SPF on your face? When and often? * Please enter your answer here.

Have you used tanning beds or excessive sun exporters that changes the color of your skin? When and how often? * Please enter your answer here.

Have you ever received Botox or collagen injections? Last time of receiving service? * Please enter your answer here.

WOMEN CLIENTS ONLY

Are you taking oral contraceptive? *

Yes

Please select at least one choice above.

Any recent changes to or from your contraceptive treatment? *

Yes

Please select at least one choice above.

If so, when? * Please enter your answer here.

Are you pregnant or planning to become pregnant? *

Yes

Please select at least one choice above.

Are you lactating? *

Yes

Please select at least one choice above.

Any menopause problems? *

Yes

Please select at least one choice above.

Explain * Please enter your answer here.

MALE CLIENTS ONLY

What is your current shaving system? *

Wet shave

Electric

Please select at least one choice above.

Do you experience irritation from shaving? *

Yes

Please select at least one choice above.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof.

First and last name: * Please enter your name.

Your Signature *

Click to sign

Please sign here.

Please Enter Date *

Please enter valid date.

Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the eyelash extension artist's day that could have been filled by another client. As such, we require 24 hours notice for any cancellations or changes to your appointment. Clients that provide less than 24 hours notice or miss their appointment will be charged 50% of your service. No call no shows will be charged the full price of service.

By checking this box, I agree to this cancellation policy. * Please check it here.

Clients under the age of 17 must have a parent or legal guardian present to provide a signature for authorization of this facial session. It is my choice to recieve spa treatments. I realize that the treatment is being given for the well being of my body and mind. I agree to communicate with my service provider any time I feel as though my well-being is being compromised. I understand that the service providers do not diagnose illness, disease, or any physical or mental disorder, nor do they prescrible medical treatment, or pharmaceuticals. I acknowledge that spa services are not a substitute for medical examination or diagnosis, and that it is recom- mended that I see a primary Health Care provider for that service. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that Janae Kirschke is a licensed profession, and that by law they have the right to refuse service on any client at any time, if they feel as though their well-being is comproised.

Clients under 17, please have legal guardian sign below to authorize this treatment.

Your Signature *

Click to sign

Please sign here.

I hereby consent to and authorize Janae Kirschke to perform the following service.

I have voluntarily elected to undergo this treatment after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by Janae Kirschke

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. 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 have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. 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.

By checking this box, I agree. * Please check it here.

Please fill your name: *

Please enter your full name.

Your Signature *

Click to sign

Please sign here.

Please Enter Date *

Please enter valid date.