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PrimeCare of Michigan > Spa Consent

Spa Consent

Facial Consent

Name(Required)
MM slash DD slash YYYY
How did you hear about us?
Emergency Contact

Medical History

Have you ever had any of the following?(Required)
Do you have any allergies to the following? (select none if you do not)(Required)
Do you (check any that apply)?

Your Skin

Are you currently using any products that contain or are you taking any of the following?
Have you received any of these skin care treatments?(Required)
What was your reaction? Check all that apply
MM slash DD slash YYYY
What skin care products do you currently use?
Do you use sunscren?
Indicate what services or areas you are interested in (check all that apply):
Consent
I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.
I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.
I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.
I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjust
accordingly.
I understand that I or the esthetician may terminate the session at any
time.
I have been given a chance to ask questions about the session
and my questions have been answered.
I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.
I, therefore, release PrimeCare Spa and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Clear Signature

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