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Release of liability and consent to treatments

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that failure to disclose medical conditions, medications, supplements, allergies, recent procedures, or other relevant information may increase the risk of an adverse reaction or affect treatment outcomes.

I understand that professional skincare treatments may produce temporary or adverse effects including redness, dryness, irritation, sensitivity, swelling, peeling, discomfort, pigmentation changes, allergic reaction, prolonged inflammation, infection, scarring, or other unexpected responses.

I understand that individual results vary and that no specific treatment outcome can be guaranteed. I understand that the treatment selected may be modified, postponed, or declined based on my health history, skin assessment, contraindications, skin response, or other safety considerations.

I understand that chemical exfoliants, LED phototherapy, high frequency, extractions, and other modalities carry specific risks and contraindications. I have had an opportunity to ask questions and receive information regarding the treatment being performed.

I understand that this service is cosmetic in nature and is not intended to diagnose, treat, or cure a medical condition. I understand that referral to a physician, dermatologist, or other qualified healthcare professional may be recommended when a concern falls outside the scope of this service.

I authorize the esthetician to perform the treatment selected based on the assessment and information provided.

CANCELLATION + APPOINTMENT POLICY

Your appointment time is reserved specifically for you. Please provide at least 48 hours' notice if you need to cancel or reschedule so the appointment can be made available to another client.

24-48 hours before the appointment: A cancellation or rescheduling fee equal to 50% of the scheduled service price may be charged.

Less than 24 hours' notice, same-day cancellations, or no-shows: 100% of the scheduled service price may be charged.

If you are feeling sick or have an unexpected circumstance outside of your control, please contact me as soon as possible. I will assess the situation and determine whether the appointment can be rescheduled without the standard cancellation fee. Please do not attend your appointment if you are experiencing symptoms that may put others at risk.

I have read and understand the cancellation and appointment policy above and agree to these terms.

Date: August 15, 2026


First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

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.


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*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information

PHOTO + RECORDING AUTHORIZATION

I consent to photographs being taken for confidential treatment documentation and progress tracking.
I consent
I do not consent
I authorize use of photographs and/or recordings for marketing / educational purposes
I do not authorize use of photographs and/or recordings for marketing / educational purposes

I understand that treatment documentation and photographs may be maintained as part of my client record in accordance with applicable privacy requirements.

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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