skin care waiver online - WaiverElectronic

Laser - Aesthetics - Medispa Intake form

First and Last Name: * Please enter your name.

Date of birth: *

Please enter valid date.

Phone numbers: (cell, home, bus.) * Please enter your phone number.

Please fill in Address: *

Please enter address.

Emergency contact name and phone # : Please enter your answer here.

Email: Please enter your email.

Would you like to sign up for our mailing list? ( BDAY specials, seasonal promo's, etc) Please enter your answer here.

Do you have any health problems or medical conditions? Please list all: * Please enter your answer here.

Any allergies? * Please enter your answer here.

List all medications/supplements that you have taken in the past month. Including any that make you photo sensativie: * Please enter your answer here.

Are you pregnant or lactating? Please enter your answer here.

Do you have cold sores/ Herpes? Please enter your answer here.

Have you been on Accutane in the past 6 months? Please enter your answer here.

What is your skin type: (Caucasian, Hispanic, Mediterranean, African-American, American Indian, other)? Please enter your answer here.

Which of the following best describes your skin type? *

I: Always burns, never tans

II: Always burns, sometimes tans

III:Sometimes burns, always tans

IV: Rarely burns, always tans

V: Brown, moderately pigmented skin

VI: Black skin

Please select at least one choice above.

Have you had any prolonged sun exposure ( or tanning salon) in the past 3-14 days? Please enter your answer here.

Have you recently used any self-tanning lotions or treatments? Please enter your answer here.

Have you used any topical creams/medications? (Retina-A, Glycolic acid, other) Please enter your answer here.

Do you have any skin conditions ( Erythema abigne, Rosacea, broken capillaries, etc.)? Please enter your answer here.

Have you used any of the following hair removal methods in the past six weeks? Please enter your answer here.

Do you have hyperpigmentation or Hypopigmentation, or have you ever had any of these reactions? Please enter your answer here.

Do you form thick or raised scars from cuts or burns? Please enter your answer here.

Have you received Gold Therapy, or any other recent procedures ( fat reducation, Botox/ fillers, etc.)? Please enter your answer here.

Would you like to receive a FREE consultation about any of our services? * Please enter your answer here.

ACKNOWLEDGMENT

I certify that the medical, personal & skin history statements are accurate. In order to provide you with the most appropriate treatments, we need you to complete the following form and answer with the most accurate recent information in order to provide safe & effective treatments. Omitting any information may cause improper treatment, it is vital that all information be disclosed. I am aware that it is my responsibility to update Art of Natural Beauty Center (AONBC) of my current medical or health conditions & medications each visit if something is to change from the original time the consent form was signed. We have a 24 hour cancellation/ appointment change policy. If 24 hour notice is not given, the appointment may be subjected to a 30% fee, deposit made will be held, or a prepaid session may be redeemed.

TREATMENT CONSENT & RELEASE

I acknowledge that all treatments offered at AONBC, including but not limited to various body treatments, skin treatments, laser treatments, colonics, weightloss, botox, injectables, coolsculpting, etc. are not exact science and no guarantees can be given concerning the expected results. I understand that some clients experiences change & improve more than others. I understand that response to treatments varies on an individual basis & specific results are not guaranteed. I understand in virtually all cases, multiple treatments are required for improvements to become apparent. I also understand that risks may occur pertaining to any particular treatments, including but not limited to; unsatisfactory results, poor healing, discomfort, redness, blistering, burning, nerve damage, scarring, change in skin pigmentation, & increased hair growth. I understand, that even though precautions will be taken in my treatment, not all risks can be known or avoided. I agree to hold harmless & release Art of Natural Beauty Center (AONBC), its technicians, & employees from all liabilities & conditions, results, known or unknown, that may arise or result from any treatments that I receive at Art of Natural Beauty Center.

Your signature *

Click to sign

Please sign here.

Your Name * Please enter your answer here.

Signature Date *

Please enter valid date.

Free skincare waiver online for you to download.