Facial Treatment | Rammy Rose

Facial Treatment: Online Consent Form

Please fill out the following form.

First name

Last name

Phone

Email

Date of birth

Year

Month

Day

Age

Please select all current and previous medical conditions listed below that apply to you:

1. Are you being treated for any other conditions not listed above?

Yes

No

2. Are you currently using Retinol cream or Accutane?

Yes

No

3. Are you using any products that contain AHA’s or Glycolic acids?

Yes

No

4. Have you had any facial piercing or tattoos?

Yes

No

5. Have you had any botox or fillers within the last 6 months?

Yes

No

6. Have you ever had any tanning services within the last 2-6 weeks?

Yes

No

7. Have you ever had any severe facial sun burns within the last year?

Yes

No

8. What skin care products are you currently using?

9. Have you had any waxing or laser hair removal done on your face within the last 72 hours?

Yes

No

10. Have you had chemical peels, microdermabrasion, or any other resurfacing treatment in the past 3 months?

Yes

No

THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS. READ IT CAREFULLY!

I confirm the answers I have given in this form are correct, and I have not withheld any information requested by this form.
I have been informed of the proper use of equipment for the services I am receiving.
I have been advised of all risks associated with the use of equipment required for the services I am receiving. I have been advised of all the risks associated with the services and procedures I will be receiving. I agree to comply with all instructions provided by the Operator.
I hereby release Rammy Rose Hair & Beauty Ltd its affiliates, officers, directors, agents, employees and contractors from liability for any injury, loss or damage that may result from my use of the equipment or from any services provided or treatment rendered. This release binds my heirs, successors and assigns.

Signature

Date picker

I declare that the info I’ve provided is accurate and complete.

Please show your filled form to the service provider, without their acknowledgement, this form cannot be submitted, and we will not start the service until the form is submitted

Service Provider Signature

I have checked the client’s form for any contraindications and have consulted with the client what the effects of these contraindications will have during and after the service