NEW CLIENT FORM Name * + Preferred Pronouns First Name Last Name Email * Phone * (###) ### #### Preferred Method of Contact * Text Email How did you hear about us? * Internet search? Social media? Referral? Have you ever had any skin treatments before? * Yes No What kind of service(s) are you in the market for? * Hydrafacial Custom Facial Peel Waxing I'm not sure Do you have any of the following? * Check all that apply. *Saying yes does not preclude you from receiving treatments. Active acne or infection Open lesion or cold sore An active infection in the treatment area Active sunburn Skin conditions such as eczema, dermatitis, or rashes An autoimmune disease such as lupus A viral concern such as HIV or hepatitis Anticoagulants Therapy Melanoma or lesions suspected of malignancy Pregnancy or lactation Neurological disorders such as epilepsy (LED Lights) Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage) Crohn’s Disease (Lymphatic drainage) Hyperthyroidism (Lymphatic drainage) Deep Venous Thrombosis (Lymphatic drainage) Lymphedema (Lymphatic drainage) None of the above Have you recently? * Check all that apply. *Saying yes does not preclude you from receiving treatments. Used Accutane, topical medications or antibiotics Had aesthetic fillers, injectables or laser treatments None of the above Pre & Post Treatment * I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre- and post-treatment. I agree Appointments and Cancellations. * I acknowledge and agree that I must provide at least twenty four (24) hours’ notice prior to cancelling or changing an appointment and that future services may be refused if I fail to provide such notice. I further acknowledge and agree that my service provider reserves the right to cancel and/or reschedule my appointment if I arrive more than fifteen (15 minutes) after my scheduled appointment time and a cancellation fee may apply. I acknowledge that I am required to provide a credit card on file in order to book services. I agree Conditions. * I hereby warrant that I am in good physical health and mental condition and that I have no fever, coughing, sneezing, allergies, ailments, impairments or other physical or mental conditions that prevent me from safely receiving services. I understand that it is my responsibility to inform service providers of any relevant medical history, medications or other conditions or factors that may affect the outcome of the services. I understand that Skin Therapy by Nancy reserves the right to refuse service to guests who appear not to be in good physical or mental health I agree Payment. * I understand that payment for services are due at the time such services are rendered. I acknowledge and agree that under no circumstances will any refund, payment or portion thereof for any services rendered be granted. I agree Release of Liability. * I hereby release Skin Therapy by Nancy, its affiliates, subsidiaries, licensees, successors and assigns, and each of their members, stockholders, directors, managers, officers, employees, advisors and agents (“Parties”) from, and covenant not to sue the Parties for, any claim or cause of action, whether known or unknown, arising out of or resulting from the Services, including, without limitation, claims for bodily injury and/or property loss or damage and/or the contraction or spread of any novel virus’ including but not limited to coronavirus. I agree Use of likeness. * I understand that my service provider may take video and/or photographs of me in connection with services, and I hereby consent to the use of my likeness, image, appearance, voice, name and/or any material based upon or derived therefrom, throughout the world, in any manner or medium now known or hereinafter devised, for all commercial and non-commercial uses in connection with goods and services. I hereby release the parties from, and covenant not to sue the parties for, any claim or cause of action, whether known or unknown, based upon or relating to the use of my likeness, including, without limitation, claims for libel, slander, defamation, and/or invasion of the right of privacy or publicity. I agree Miscellaneous. * I acknowledge and agree that this release is binding on my heirs, personal representatives, successors and assigns. I acknowledge and agree that this release will be governed by the laws of the State of Illinois. I hereby agree to irrevocably and unconditionally submit to the jurisdiction of any federal or state court of competent jurisdiction sitting in Cook County, Illinois. if any provision of this release is determined to be illegal, unenforceable or void, then any such provision shall be severed and the remainder of this Release shall be enforceable. I agree Consent * The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have treatments by the staff at Skin Therapy by Nancy I agree Date * MM DD YYYY Digital Signature * Every human is required to read and digitally sign this consent and release form prior to receiving any services with Skin Therapy by Nancy including, without limitation; waxing, facials, microdermabrasion, chemical peels, light therapy, treatments (collectively “services”). In consideration for the receipt of services, the undersigned hereby agrees that by adding my initials below that this serves as a digital signature agreeing to all statements above. Thank you!
