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
COVID-19 Liability Release Waiver
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic. I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. Part of this practice and team of health providers’ role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.
To proceed with care in consideration the foregoing, I confirm and agree to the the following: *

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted and assume the risk that I may be exposed. I understand that, while I understand the potential risks associated with proceeding with a visit and/or treatment during the COVID-19 pandemic, I am opting electively to proceed with this visit and/or elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office. I confirm have not experienced symptoms that of fever, fatigue, difficulty in breathing, dry cough, runny nose, sore throat, lost of taste or smell, or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days. I understand travel increases my risk of contracting and transmitting the COVID-19 virus that I have not, nor any member(s) of my household, traveled internationally, or domestically within the United states by air, bus, or train in the last 14 days. I have not, nor any member of my household, visited any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days . I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days. I am informed that this facility its staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with today’s consultation and/or treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective visit and/or treatment and give my express permission to this practice and the staff to proceed with providing care. I understand that virtual telehealth options have been made available for medical consultations at this practice. I have been offered a copy of this consent form.
knowingly and willingly consent to today’s visit and treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered to my satisfaction. I have read, or have had read to me, the above COVID-19 risk informed consent to treat. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek care from this office.

By signing this form I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected COVID-19 by my mere presence within the establishment and such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that th risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I hereby release McLean Dermatology and Skincare Center, LLC and Skinkure, LLC from any and all claims arising from or in connecting with any direct COVID-19 impact while visiting.
Client Name *

First Name Last Name
Name of Parent or Guardian if Client is Under the Age of 18

First Name Last Name
Signature *

Clear
COVID-19
Should be Empty:

Spa Registration

COVID-19 Liability Release Waiver

COVID-19