European Facial European Facial Consent Form Esthetic skin care is not an exact science. Each individual’s medical history, lifestyle and skin behaves differently and there is therefore no way to guarantee a specified result or guarantee freedom from adverse side effects. The estheticians will take all possible precautions to avoid such complications. It is therefore imperative that you disclose all of your information candidly so that your treatment can be altered to help avoid complications. Adverse side effects of facials include but are not limited to: swelling of the face, redness of the treated area, blistering of the skin, crusting of the skin, scars, infection, cuts and burns, change of pigmentation of the skin, allergic reaction to the products used and stinging. I have had the opportunity to ask my esthetician any questions I may have. I understand this is a cosmetic procedure with risks and potential side effects, and I voluntarily wish to have the services provided with knowledge of the potential side effects. I understand that any false information I have provided may lead to undesirable consequences and affirm I have truthfully discussed my personal and medical history to my esthetician. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects. I understand that the esthetician does not diagnose illness, disease, or any other physical or mental conditions. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against ANEW, LLC., dba ANEW Body Beauty and Wellness Spa and its service providers. I have read the above information and if I had any concerns, I have addressed them with my esthetician. I give permission to my esthetician to perform the procedure we have discussed and will hold them harmless from any liability that may result from this treatment. I have given an accurate account of all known allergies or prescription drugs or products I am currently ingesting or using topically. This waiver will be kept on file and will apply to each and every facial service I receive today and in the future. By signing this document state that I have read, agree and understand the terms herein and voluntarily have accepted the service and any potential risks that may be associated with the service.Name(Required) First Last Date of Birth MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) CommentsPlease Check any of the following that apply: Medications Blood Pressure High Blood Pressure Low Allergies Surgeries Epilepsy Metal Implants Heart Problems Pacemaker Hormone Problems Birth Control Thyroid Problems Have you had chemical peels/laser treatments within the last month?(Required) Yes No Are you on dermatologist prescribed medication?(Required) Yes Please Elaborate No Treatment Priorities (What do you want to improve):What are the areas of concern for your skin? (Check all that apply) Breakouts/Acne Uneven Skin Tone Dehydration Dull/Dry skin Blackheads/Whiteheads Wrinkles/Fine Lines Redness Excessive Oil Textured Skin Sun Spots Hyperpigmentation Hypopigmentation Terms of Service(Required) I agree to the Terms of ServiceI understand that withholding information or giving misinformation can contraindicate products used resulting in skin irritation. I understand that this is my responsibility to provide accurate information and if it is not provided, ANEW, LLC., dba ANEW Body Beauty and Wellness Spa is not liable.Signature(Required) Daljeet Arora2023-11-03T18:36:12+00:00
