Spa Waiver

Spa Registration

Welcome to Skinkure Spa!
Client Name

First Name Middle Name Last Name
Sex
Date of Birth

Month Day Year
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you ever had a facial before?

Yes No
How do you prefer the pressure of your massage?

Light Medium Firm
Are you (or might you be) pregnant?

Yes No
If yes, how many months pregnant are you?
Do you have drug allergies?

Yes No
If yes, please list the names of the medications you are allergic to here.
Are you allergic to any of these products?

Aspirin Skincare products Citrus Tree nuts Salicylic acid Benzoyl Peroxide Latex
Do you have any specific skin concerns or problems? Check all that apply.

Rosacea Tendency to Burn Easily Acne Breakouts Scars
Do you have any of these medical conditions? Check all that apply.

Cancer Heart Disease Epilepsy Varicose Veins Fluid Retention Headaches Metal implants Osteoporosis Osteoarthritis Rheumatoid Arthritis Blood Clotting Abnormality Fibromyalgia Easy Bruising Skin Rash Abscess/Open sores Skin Sensitivity Hepatitis C Herpes I or II HIV Positive Inner Ear Problem Thyroid Imbalance Asthma Chronic Fatigue Syndrome Diabetes
Please list any skincare products you currently use.
Are you using any of these skincare products?

Tretinoin (Retin-A) Accutane Renova Hydroquinone
Have you ever had any of the following treatments?

Chemical Peel Laser Microdermabrasion Skin resurfacing Treatment
If yes, when was your last treatment?
Have you been under the care of a dermatologist in the last year?

Yes No
If yes, for what condition were you treated?
What are your skincare goals?
Waiver
- I understand and acknowledge there are risks involved with the facials, peels, microdermabrasion, microcurrent, eyelash extensions, tinting, and waxing.
- I have had the opportunity to ask questions regarding these risks and other possible complications.
- I understand that any false or misleading information I have given may lead to undesirable results and complications or effects and hereby waive Skinkure's liability if such results or complications occur.
- I further understand my failure to follow post care instructions may also lead to undesirable results, complications, or effects and hereby waive Skinkure's liability if such results or complications occur.
- In consideration for Skinkure Spa performing this procedure any future procedures, I agree I will assume the risk and full responsibility ofr any and all injuries, losses, or damages which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure or future procedures are performed.
- I understand that the esthetician does not diagnose illness, idsease, or any other physical or mental conditions.
- Any sexual misconduct exhibited by the client will result in immediate termination of the session, and the client will be liable for the scheduled appointment.
- 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 Skinkure, LLC, its owners, employees, or agents for negligence, injury, loss, death, costs, or other injuries, or damages to me as a result of this procedure.
- I agree to this waiver and release and bind the members of my family, and any spouse or domestic partner, if I am alive, as well as my estate, family, heirs, administrators, personal representatives, or assigns if I am deceased, and shall be deemed as a "Release, Waiver, Discharge, and Covenent" not to sue Skinkure spa.
Maximum liability

Skinkure Spa's maximum aggregate liability to patient related or in connection with the procedures performed by Skinkure, its employees, or agents, will be limited to the total amount paid to Skinkure by the patient for the procedure described in this authorization and consent.
This information will be treated confidentially. In order to maximize the effectiveness and saftey of yur treatments, please give your feedback during and at the end of the session. This will help in tailoring the treatment to best suit your preferences.

I have read the above information and will discuss pertinent details with my esthetician. I understand that this work does not constitute emdical treatment; it is a form of health and wellness maintenance. I take full responsibility for alerting my esthetician to any physical conditions thta would affect this treatment.

If you are under 18 a parent or guardian must sign below to give permission for you to be treated by one of our licensed estheticians.
Name of Parent or Legal Guardian Completing this Form (If Applicable)

First Name Last Name
Relationship to Patient
Signature

Clear
Date signed
Should be Empty:

Spa Registration