Loading...

This is our new client waiver,  if you have any questions or concerns please ask!

 

 

Please select who will be receiving a service...
AdultMinor
Continue
First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Healthcare Information:

What are your pronouns? *

What are your skincare goals? *
How do you describe your skin?*
Oily
Dry
Sensitive
Normal
Irritated
Flushed
Flaky
Damaged
Combo
Smoking?*
No
Yes
Alcohol?*
No
Yes
Coffee/Tea?*
No
Yes
Do you often feel: *
Angry
Sad
Frustrated
Stressed
Overwhelmed
Worried
Depressed
Irritable
Anxiety
none of the above
Check any of the following conditions that you have/have had in the past year: *
Skin disorders
Skin cancer
Diabetes
Heart disease
High/Low DP
Hepatitis
Seizures
Anemia
Tuberculosis
STD's
Auto-Immune dis.
Heart attack
Paralysis
HIV/AIDS
High/Low thyroid
Arthritis
High cholesterol
Stroke
Bleeding disorder
Asthma/Wheezing
Enlarged glands
Frequent colds
Poor circulation
none
Skin Contraindications: *
Boils
Bruise easily
Itching/Rash
Sores that won't heal
Sweating
none
Do you use: *
Retin-A
Renova
Glycolic acid
Differin
Hydroxyl acid
AHA
Salicylic acid
Vitamin A
Retinal
none
Have you sun-tanned, received a spray tan, have on self-tanning lotion or used a tanning bed in the last 3weeks?*
No
Yes
Have you been under the care of a physician, dermatologist or another medical professional within the past year?*
No
Yes
Are you or could you be pregnant?*
No
Yes
Are you trying to become pregnant?*
No
Yes
Are you undergoing fertility treatments?*
No
Yes
Are you on birth control?*
No
Yes

PMS symptoms? *

list all allergies above. *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 Liability Waiver By checking here, you agree to the following: You hereby agree to release and forever discharge The Yoni Specialist LLC and its affiliates, successors, assigns, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, “Representatives”), in their individual and/or corporate capacities, from causes of action of any nature and kind, known or unknown, which you may have against The Yoni Specialist LLC or any Representatives arising out of or relating to any injury, loss or damage of any kind to person or property that may be sustained as a result of receiving treatments and/or services with The Yoni Specialist LLC (the “Services”). The Yoni Specialist LLC is not responsible for any bodily injury, allergic reactions or bodily harm that occur by misusing any product and/or service The Yoni Specialist LLC sells, offers, or performs. Any injury or reaction occurring from a product and/or service purchased from The Yoni Specialist LLC is your sole responsibility. You understand that an accident, injury, or a reaction may occur while participating in the Services and that The Yoni Specialist LLC assumes no responsibility. The Yoni Specialist LLC will not be held responsible for any damage, liability, claim, or lawsuit related thereto. To the best of your recent knowledge, you hereby represent and warrant that you have been truthful and have advised the staff of The Yoni Specialist LLC of any new or old medical conditions, which you may or may not be being treated for. You agree to indemnify The Yoni Specialist LLC and its Representatives against any and all claims, actions, lawsuits, damages, and judgements, including attorney’s fees, arising out of, or relating to your use of, the Services. This statement shall not be in any way construed as an admission of The Yoni Specialist LLC of any liability and/or responsibility.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!