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Skin Essentials

Cancellation Policy:
If an appointment needs to be cancelled or rescheduled we require a 24 hour notice. If you fail to notify us of your need to cancel or reschedule within 24 hours of your appointment time, you will be charged a cancellation fee up of 50% of the price of the service. Future appointments will be cancelled if there are un-paid cancellation fees. Multiple late cancellations may require you to pre-pay for future services scheduled. We may require a credit card be kept on file to reserve an appointment.

Liability Waiver:
All of the information I’ve provided is true and accurate to the best of my knowledge. I take full responsibility for alerting my Esthetician to any physical or mental condition which would affect my service or results. I understand that practitioners who rent space at Skin Essentials are not employees of Skin Essentials LLC but are independent business entities. Skin Essentials LLC is not liable for negligent behavior or injury caused by these independent entities. I understand and acknowledge there are risks involved with the treatment of facials, peels, microdermabrasion, massage, hair removal and eyelash services. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive Skin Essentials LLC’s and my esthetician’s liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby waive Skin Essentials LLC’s and my esthetician’s liability if such results or complications occur. I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing spa services or side effects I may experience after the services are performed. I understand that Skin Essentials and my esthetician do not guarantee end results or diagnose illness, disease, or any other physical or mental conditions.

COVID-19/Infectious Disease Notice:
The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Skin Essentials wants to ensure you are aware of the additional risks of contracting COVID-19 associated with spa and beauty services.The COVID-19 virus has a long incubation period. You or your practitioner may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to the limited availability for virus testing. You cannot wear a protective mask over your mouth and nose during some spa services such as lip waxing and facials, which could increase your risk of being exposed to the COVID-19 virus.

I confirm that I have read the notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus during a spa treatment. I understand and accept the additional risk of contracting COVID-19 from contact at Skin Essentials. I also acknowledge that I could contract the COVID-19 virus from outside of Skin Essentials and unrelated to my visit here.

Today's Date: August 10, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Participant's 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.
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How did you hear about us?*

If Other

Referred by (If referred by a friend, please let us know, as we offer a referral program)
Personal Health History Please check all that apply to you:
Pregnant/lactating in the last 6 months.
Connective tissue disorder or autoimmune disease
History of serious allergies (anaphylaxis)
History of facial cold sores or genital herpes
History of hypertrophic scarring (thick, raised scars)
Bleeding tendency
Currently taking blood thinning medication
Active inflammation or acne
Communicable/Infectious disease.
HIV or exposure to person with known HIV
Hepatitis or known exposure to hepatitis A, B or C
Diabetes
Smoker
Hormone Replacement Therapy
Use of Oral Contraceptives 
 (In the past 6 months)
Under a doctors care for skin condition
Excessive sun exposure
Taking immunosuppressive drugs, steroids in the past 6 months.
Use of Accutane (in the past 6 months
Pacemaker or any medical implants, dental implants, metal implants of any kind
Previous reaction to hair color or dye

Communicable/Infectious disease, If so please list

Taking immunosuppressive drugs, steroids in the past 6 months. 
 If so, please list

LIST ANY ALLERGIES/ADVERSE REACTIONS TO FOOD, PRODUCTS, MEDS, LATEX ETC

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ALL SKINCARE PRODUCTS YOU ARE CURRENTLY USING
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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