HydraFacial Waiver - Shape it Up Contouring

Are you currently taking any medications or supplements?

Yes

If yes, please list.

Do you use acne medication?

Yes

Are you taking oral contraceptives?

Yes

If yes, please list.

Do you have any specific skin care problems / allergies pertaining to your face or body?

Yes

If yes, please list.

Have you ever had chemical peel, laser, microdermabrasion, or any skin resurfacing treatments?

Yes

Do you wear SPF?

Yes

Do you experience an oily shine during the day?

Yes

Are you currently pregnant and/or nursing?

Yes

Are you currently having your menstrual period?

Yes

What skin care products do you currently use?

What temperature of water do you cleanse with? (Cold, Warm, Hot)

What are your skin care goals?

Please Read each and Click to check that you fully understand.

If I experience any pain or discomfort during the session, I will immediately inform the provider so that the products and/or technique may be adjusted to my level of comfort.

I understand that provider is not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.

I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.

I agree to keep the provider updated as to any changes in my medical profile during the session and understand that there shall be no liability on the provider's part should I fail to do so.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

I also understand that the provider reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which facial treatments are contraindicated.

Client Name

First

Last Name

Last

Phone

Client Signature

Clear

If you are human, leave this field blank.

(951) 635-6304

Consent to Treatment Form HydraFacial

Please Read each and Click to check that you fully understand.

Murrieta Body Contouring
(951) 635-6304

(951) 635-6304

Consent to Treatment Form HydraFacial

Please Read each and Click to check that you fully understand.

Murrieta Body Contouring(951) 635-6304

Murrieta Body Contouring
(951) 635-6304