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Skin Analysis Form

Please read carefully before you sign the waiver and consent to have facial treatment(s) at Ease Medspa & Wellness Group.

Acknowledgment:

  • 24-hour Cancellation & Rescheduling Policy: I do understand that my appointment is one-on-one service and it is my responsibility to Call, Email or send Message 24 hoursprior to my designated appointment if I need to Reschedule or Cancel. 
  • No Show Policy:I understand that if I miss my appointment without canceling 24-hours in advance, it will be recorded as a “No Show” in my file. 
  • I do understand the Cancelation, Rescheduling and No Show policy; and I agree to pay the appropriate fee of $30 if I fail to cancel or reschedule 24 hour in advance.The same rule applies to No Show appointments. 

​


Dated: January 19, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information

General Health Information


Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Do you have any allergies?*
No
Yes
Are you taking any medication for Acne?*
No
Yes
Have you experienced skin sensitivity to any product or facial treatments?*
No
Yes

Skin Evaluation

Choose one of the following which best describes your skin type:
Normal
Oily
Dry
Combination
Sensitive
Do you have any of the following skin conditions?*
Acne
Eczema
Hyperpigmentation
Other
Psoriasis
Rosacea
None of the above
What would you like us to focus on for your treatment?*
Acne
Hyperpigmentation
Clogged pores/Blackheads
Wrinkles/Fine lines
Dehydration
Stretch marks
Other
Which skin treatment(s) would you be interested in at Ease Medspa?*
Custom Facial
Micro-current Lifting Facial
Acne Control Facial
Advanced Combination Anti-aging Facials
Chemical Peels
Dermaplaning
Casmara 6-Phases Purifying
Microdermabrasion
LED Light Skin Therapy
Facial Acupuncture

I hereby agree and confirm that:

  • I understand that the treatments and services provided by Ease Medspa & Wellness Group are intended for general wellness purposes and are not intended to substitute professional medical treatment for any condition, medical or otherwise;
  • I have disclosed all my known health conditions, limitations, allergies and physical ailments to Ease Medspa & Wellness Group, and agree to keep such information up to date and accurate;
  • I understand the product(s) and treatment(s) to be provided to me and my queries on the same (if any) have been addressed to my satisfaction, and I agree to accept any risks arising in connection therewith; and
  • I shall fully release, indemnify and hold harmless Ease Medspa & Wellness Group and its employees from and against all liabilities, claims, expenses arising out of or in connection with the products and treatments provided to me.
  • I further agree that this consent supersedes any previous verbal or written disclosures, and shall remain valid for all future treatments.
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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