SKIN CARE CUSTOMER DATA PROFILE (Date: ___/___/____ )
First Name ________________________ Last Name ______________________
Birthday: ___/___/____
Address: __________________________________________________________________
City ______________, State ___ Zip__________
Home #: _______________ Work #: ___________ Cell #: ______________
Occupation: _____________________ Age: under 21 21-30 31-50 over 50
Email address: ______________________________Referred by:________________
Would you like to be notified via email about future promotions and news? _no _yes
Have you ever had a facial treatment before? _ No _Yes, when? _______________
Have you had body Sculpting before? ____no ____Yes, When?__________________
Which of the following best describes your skin type? (Please circle one type number)
I Creamy complexion Always burns easily, never tans
II Light Complexion Always burns, tans slightly
III Light/Matte Complexion Burns moderately, tans gradually
IV Matte Complexion Seldom burns, always tans well
V Brown Complexion Rarely burns, deep tan
VI Black Complexion Never burns, deeply pigmented
Have you ever had chemical peels, laser or microdermabrasion?_ No _Yes
In the last month? _ No _Yes
Do you use Retin-A, Renovo, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? _ No _Yes describe:
Have you used any of these products in the last 3 months? _ No _Yes
What skin care products are you currently using? (List brand where known)
Soap ___________________________ Night Moisturizer_______________
Toner ___________________________ Mask_________________________
Eye Product ______________________ Cleanser ______________________
Day Moisturizer ____________________ Exfoliator_________________________
Scrubs ___________________________ Makeup products___________________
What areas of concern do you have regarding your skin: (Please check any that apply)
Breakouts/acne _ Uneven skin tone _ Dehydrated _
Blackheads/whiteheads _ Redness/ruddiness _ Dull/dry skin _
Excessive oil/shine _ Wrinkles/fine lines _ Flaky skin _
Sun spot/liver spot/brown spot _ Rosacea _ Sun damage _
Broken capillaries _ Other_________________________________
Eyes: dehydrated _ wrinkles _ puffiness _ dark circles _ Other: ______________
Lips: dehydrated _ cracked/chapped lips _ Other: ____________________________
What SPF do you use on your face? ____________ How often/when? _____________
Have you had any recent tanning bed or sun exposure? _ No _Yes
Have you experienced Botox, Juvederm or Collagen injections? _ No _Yes
Female Clients Only:
Are you taking oral contraceptives? _ No _Yes
Any recent changes with your contraceptive treatment? _ No _Yes
If so, what and when: __________________________
Are you pregnant or trying to become pregnant? _ No _Yes
Any menopause problems? _ No _Yes
Are you undergoing any hormone replacement therapy? _ No _Yes
Male Clients Only:
What is your current shaving system? Wet shave _ Electric _
Do you experience irritation from shaving? _ No _Yes Ingrown hairs? _ No _Yes
Clients Signature_______________________________________________________
CHECK ALL THAT APPLY:
ABDOMEN/WAIST : ____ UPPER ARMS: _____ LOWER THIGHS: _____ INNER THIGH: ____ UPPER THIGHS: _____ UPPER BACK: _____
LOWER BACK: _____ BUTTOCKS: _____ HIPS:______CALVES:
JOWLS: _____ NECK: _____
Target date of achieving your improvement goals:
Rate your level of commitment to achieving your personal improvement goals from a scale of
(1 - 10 with 10 being the highest)___________________
Clients Signature:______________________________________Date____________________
Present Medical History
Check if you answer YES to any of these questions:
If you answered YES to any of these questions YOU MAY NOT be eligible for the treatment and or need to talk with your doctor before proceeding.
EXPLAIN YES ANSWERS:
Female Clients: When is your next menstrual cycle due to begin? ____________
Current Conditions, Previous Discomfort, Stinging or Adverse Reactions
Please check any that apply.
Allergy & Medical History:
Do you have allergies? ❏Yes ❏No (please specify.) _____________________________________________ Have you had any skin problems in the past 4 weeks? ❏Yes (please specify.) ❏No _____________________ Have you recently had a chemical peel? ❏Yes (Specify date.) ❏No _______________
Do you use products containing retinol or AHA? ❏Yes (please specify.) ❏No __________________________
Any medications (Prescribed and Over the Counter including vitamins/herbs/supplements) or Skincare products you are currently using:
________________________________________________________________________________________
Other relevant information: (Any illnesses or conditions you are being treated by a physician for?) ______________________________________________________________________________________________________________________________________________________________________________
I certify that the medical history provided today is accurate and complete to the best of my knowledge.
Client Signature:_________________________________________ Date:_________________________
Technician Signature:_____________________________________ Date:________________________
Patch Test
Would you like to have a patch test performed? ❏Yes ❏No ❏Not required
Technician Signature: _____________
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity/allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and service(s).
Client Signature:_______________________________________ Date:________________________
Technician Signature:___________________________________ Date:________________________
Company Lateness and Cancellation Policy
Our time is very valuable. To ensure that we can provide all of our clients with excellent service, we ask that you be on time to all of your appointments. Please arrive at least 5 to 10 minutes prior to your scheduled time to ensure you receive your full appointment time.
In the event that you should be tardy, we ask that you be considerate and call to inform us of your situation so we may take necessary action or make special arrangements. Please be aware that if you are 15 minutes or more late to your appointment, you will be cancelled. You will need to reschedule. NO EXCEPTIONS.
In the event that you need to cancel or reschedule your appointment, we asked that you notify us at least 48 hours in advance of your scheduled appointment.
● WE RESERVE THE RIGHT: to charge 50% of the scheduled service price when cancelling or rescheduling less than 48 hours prior to your appointment.
● WE RESERVE THE RIGHT: to charge 100% of the scheduled service(s) on No-Shows. ** ALL CLIENTS MUST HAVE A CREDIT CARD ON FILE PRIOR TO BOOKING AN APPOINTMENT FOR ANY SERVICE TO GUARANTEE YOUR APPOINTMENT **
The satisfaction of our clients is our main priority. We offer prompt solutions to any problems or concerns that may occur.
We do not offer refunds, credits, or exchanges for products sold or services rendered.
If, for any reason, you feel dissatisfied with any of our services, please bring this to our attention:
I understand and acknowledge Colorado Waxing & Skin Care’s policy regarding lateness and appointment cancellations.
Client Signature:____________________________________________Date:__________________
ULTRASONIC CAVITATION / LIPO SCULPT CONSENT FORM
We value your privacy. We do not disclose your personal information or share it with other outside entities unless otherwise authorized by you. Your information is used for internal statistics, marketing, or educational purposes. We do not send spam emails. We only communicate with our clients and potential clients regarding new services, price changes, special offers, and appointment notifications. PRINT NAME Client: ______________________________________________________________________________________ DATE: ______________
PURPOSE/PROCEDURE:
LIPO SCULPT: HIGH INTENSITY LIGHT TECHNOLOGY REDUCES POCKETS OF UNWANTED FAT PAINLESSLY WHEN DIET AND EXERCISE FAIL. HIGH INTENSITY LIGHT BREAKS DOWN EXTREMELY STUBBORN FAT CELLS.
ULTRASONIC CAVITATION: THE TREATMENT INCLUDES, BUT IS NOT LIMITED TO, THE USE OF HIGH POWER LOW FREQUENCY ULTRASOUND. CAVITATION USES 40 KHZ FREQUENCY ULTRASOUND TO PENETRATE THE SKIN AND ASSIST WITH THE BREAKDOWN OF FAT CELLS BY CREATING MICROBUBBLES THAT INCREASE THE PRESSURE AROUND THE ADIPOCYTE AND FORCES THEM TO IMPLODE, THUS BREAKING DOWN THE ADIPOCYTES CELL MEMBRANE.
RISKS: JUST AS THERE MAY BE BENEFITS TO THE PROCEDURES PROPOSED, I UNDERSTAND THAT ALL PROCEDURES INVOLVE RISKS TO SOME DEGREE. THE ULTRASOUND CAVITATION TREATMENT CARRIES WITH IT POSSIBLE HEALTH COMPLICATIONS AND CONSEQUENCES, WHICH INCLUDE, BUT ARE NOT LIMITED TO, THE RISKS OF KIDNEY FAILURE, LIVER FAILURE, PACEMAKER FAILURE, BIRTH DEFECTS, MISCARRIAGE, HYPERCHOLESTEROLEMIA, PANCREATITIS, INFECTION, SCARRING, ALLERGIC REACTIONS TO ANY PRODUCTS USED, EXCESSIVE THIRST, DEHYDRATION AND NAUSEA.
DISCOMFORT: PRESSURE IS APPLIED, ACCOMPANIED WITH A LIGHT BUZZING NOISE IN THE EAR. PATIENT MAY EXPERIENCE A TINGLING/HEATED SENSATION.
REDDENING: TREATMENT MAY CAUSE A REDDENING OF THE AREA. THE REDDENING WILL USUALLY GO AWAY IN 1 TO 2 HOURS FOLLOWING TREATMENT. IN SOME INSTANCES, THE REDNESS CAN PERSIST FOR SEVERAL DAYS.
SWELLING: TREATMENT MAY CAUSE SWELLING, WHICH WILL USUALLY GO AWAY IN 3 TO 5 DAYS OR LESS.
BRUISING: TREATMENT MAY CAUSE BRUISING, BUT THIS IS EXTREMELY UNCOMMON.
RESTRICTIONS: YOU SHOULD AVOID ALCOHOL AND CAFFEINE THE DAY OF THE PROCEDURE AND 24 HOURS FOLLOWING TREATMENT. MAKE SURE TO ADHERE TO A HEALTHY DIET THAT WILL NOT COUNTERACT THE PURPOSE OF THE TREATMENT.
CONSENT: YOU HAVE READ THIS FORM AND UNDERSTAND IT. YOU REQUEST THE PERFORMANCE OF THE PROCEDURE DESCRIBED ABOVE. YOU HAVE BEEN GIVEN A COPY OF THIS CONSENT FORM UPON REQUEST. YOUR CONSENT AND AUTHORIZATION FOR THIS PROCEDURE IS STRICTLY VOLUNTARY. BY SIGNING THIS INFORMED CONSENT FORM, YOU HEREBY GRANT AUTHORITY TO PERFORM THERMA-LIFT.
THE NATURE AND PURPOSE OF THIS PROCEDURE, WITH POSSIBLE COMPLICATIONS, HAVE BEEN FULLY EXPLAINED TO YOUR SATISFACTION. NO GUARANTEE HAS BEEN GIVEN BY ANYONE, AS THE RESULTS THAT MAY BE OBTAINED BY THIS TREATMENT MAY VARY.
Photo Release Waiver: I understand that for legal purposes, Colorado Waxing and & Skin Care, will take photos before and after the service is complete.
Client Initials ______
I hereby grant and authorize Colorado Waxing and & Skin Care the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites, and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.
Client Initials ______
I understand and agree that these materials shall become the property of Colorado Waxing and & Skin Care and will not be returned.
Client Initials ______
I have fully read and understand and hereby acknowledge the contents of this consent form to its entirety including my responsibilities detailed throughout this document. I have been given the opportunity to ask questions about the products, application procedure, and any risks or hazards involved.
Client Signature:________________________________________________________________ Date:________
Technician Signature:____________________________________________________________ Date:________
Procedure Consent
Although we take every precaution to ensure your safety and well-being before, during and after your service, please be aware of the possible risks below. Please initial.
________ I understand that body contouring can have certain side effects such as skin removal, redness, swelling, tenderness,Bruising, cardiac issues etc.
________ I understand that body contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition
________ I give permission to my therapist to perform the procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment.
________ I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions.
________ I understand that in the event I have questions or concerns regarding my treatment, I will consult the esthetician immediately.
Client Signature:________________________________________________________________ Date:________________
TREATMENT DISCLOSURE: THE TREATMENT IS A PROCESS AND SUBSEQUENT VISITS MAY BE NECESSARY IN ORDER TO ACHIEVE THE DESIRED RESULTS. SUBSEQUENT VISITS ARE SUBJECT TO ADDITIONAL CHARGES PER VISIT, WHICH DEPEND ON THE AMOUNT OF WORK NEEDED. ACTUAL RESULTS VARY FROM PERSON TO PERSON AND COLORADO WAXING & SKIN CARE DOES NOT GUARANTEE ANY SPECIFIC RESULT.
AFTERCARE: CLIENTS ARE REQUIRED TO DRINK AT LEAST 1.5 LITERS OF WATER ON A DAILY BASIS WHEN UNDERGOING THIS PROCEDURE. ALSO, BE PREPARED TO COMPLETE A 30-45 MINUTE CARDIO WORKOUT. AFTERCARE INSTRUCTIONS HAVE TO BE FOLLOWED EXACTLY WHETHER GIVEN IN WRITING OR VERBALLY. FAILURE TO FOLLOW AFTERCARE INSTRUCTIONS MAY COMPROMISE THE FINAL RESULTS OF THE TREATMENT.
RELEASE: I RECOGNIZE THAT THERE ARE CERTAIN INHERENT RISKS ASSOCIATED WITH THE ABOVE DESCRIBED TREATMENT AND I ASSUME FULL RESPONSIBILITY FOR PERSONAL INJURY TO MYSELF. IN EXCHANGE FOR SUCH TREATMENT, I HEREBY FULLY RELEASE AND FULLY DISCHARGE COLORADO WAXING & SKIN CARE (INCLUDING ITS OFFICERS, MEMBERS, OWNERS, EMPLOYEES AND AGENTS) FROM ANY AND ALL DAMAGES, COSTS, EXPENSES, LIABILITIES, CAUSE OF ACTION, CLAIMS AND DEMANDS OF WHATEVER CHARACTER IN LAW OR EQUITY, WHETHER KNOWN OR UNKNOWN, DIRECT OR INDIRECT, ASSERTED OR UNASSERTED AND WHETHER OR NOT IN ACCOUNT OF MYSELF OR COLORADO WAXING & SKIN CARE OR OTHER THIRD PARTIES WHOSE CLAIMS MAY ARISE OUT OF, OR RELATE TO, THE TREATMENT I HAVE REQUESTED COLORADO BODY WAXING & SKIN CARE TO PERFORM. IT IS THE INTENTION OF THE PARTIES, THAT THIS AGREEMENT BINDS ALL PARTIES WHOSE CLAIMS MAY ARISE OUT OF, OR RELATE TO, THE TREATMENT OR SERVICES PROVIDED BY COLORADO WAXING & SKIN CARE, INCLUDING ANY SPOUSE OR HEIRS OF THE CLIENT/PATIENT AND ANY CHILDREN, WHETHER BORN OR UNBORN. ANY LEGAL OR EQUITABLE CLAIM THAT MAY ARISE FROM PARTICIPATION SHALL BE RESOLVED UNDER STATE OF COLORADO LAW.
RESULTS: I AGREE THAT RESULTS ARE SUBJECTIVE AND THAT MY LIFESTYLE CAN MITIGATE THESE RESULTS; THEREFORE, THE COST OF THE PROCEDURES ARE NON-REFUNDABLE.
INDEMNIFICATION: I AGREE TO INDEMNIFY, HOLD HARMLESS AND DEFEND COLORADO WAXING & SKIN CARE (INCLUDING ITS OFFICERS, MEMBERS, OWNERS, EMPLOYEES AND AGENTS) AGAINST ALL THIRD PARTY CLAIMS, CAUSES OF ACTION, DAMAGES, JUDGEMENTS, COSTS OR EXPENSES, INCLUDING ATTORNEY’S FEES AND ANY OTHER LITIGATION COSTS, WHICH MAY IN ANY WAY ARISE FROM THE ABOVE DESCRIBED TREATMENT I HAVE REQUESTED COLORADO WAXING & SKIN CARE TO PERFORM.
ARBITRATION: IT IS UNDERSTOOD THAT ANY DISPUTE ARISING AS TO MALPRACTICE OF THE ULTRASOUND CAVITATION/LIPO SCULPT TREATMENT SHALL BE DECIDED BY A NEUTRAL ARBITRATOR. ANY ARBITRATION WILL BE GOVERNED BY STATE OF COLORADO ARBITRATION STATUTES. THE FEES FOR THE ARBITRATOR WILL BE SPLIT PRO-RATA AMONG THE PARTIES AND EACH PARTY WILL BE RESPONSIBLE FOR THEIR OWN ATTORNEY’S FEES AND COSTS. ANY ACTION TO COLLECT FEES FROM THE CLIENT/PATIENT FOR THE TREATMENTS PERFORMED MAY BE BROUGHT IN ANY COURT LOCATED IN STATE OF COLORADO AND PREVAILING PART. IN SUCH COLLECTION, ACTIONS SHALL BE ENTITLED TO RECOVER ANY REASONABLE ATTORNEY’S FEES AND COSTS. FILING OF ANY ACTION IN ANY COURT TO COLLECT ANY FEE FROM CLIENT/PATIENT SHALL NOT WAIVE THE RIGHT TO COMPLETE ARBITRATION OF ANY MALPRACTICE CLAIM.
BY SIGNING THIS AGREEMENT, I CONFIRM THAT I AM OVER THE AGE OF 18. I UNDERSTAND THAT THE PROCEDURE IS PERMANENT, THAT SUCH PROCEDURE HAS POSSIBLE ADVERSE CONSEQUENCES AND THAT THE PROCEDURE IS FOR COSMETIC PURPOSES ONLY. I CERTIFY THAT I HAVE READ THE ABOVE PARAGRAPHS, FULLY UNDERSTAND THE PROCEDURE’S RISKS AND HEREBY CONSENT TO THE INDICATED PROCEDURES. THIS MEANS THAT I ACCEPT FULL RESPONSIBILITY FOR THESE AND/OR ANY OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE PROCEDURE, WHICH IS TO BE PERFORMED AT MY REQUEST. ACCORDING TO THIS AGREEMENT, I HEREBY AGREE TO ARBITRATION OF ANY MALPRACTICE CLAIM. I FURTHER UNDERSTAND THAT THE COST OF THESE PROCEDURES ARE NON-REFUNDABLE AND THAT BY SIGNING THIS AGREEMENT, I VOLUNTARY SURRENDER CERTAIN LEGAL RIGHTS.
CLIENT Signature: ______________________________________________________________________________ DATE: _______________
TECHNICIAN SIGNATURE;________________________________________________________________________DATE_________________