01
.
Registration
02
.
Consent & Waivers
Facial Registration & Consent Form
Name
Phone
Email
D.O.B.
How did you hear about us?
Address, City & Zip Code
Have you ever had a facial before?
Yes
No
Please tick if any of the following have previously or currently apply
Currently Pregnant
Injuries
Using Vitamin A
Using Glycolic
Using AHA / BHA
Botox
Fillers
Currently Breast Feedin
Using Retin-A
Cold sores
Menopause
Currently Sunburnt
Metal Braces or Fillings
Contraception Pill
HRT
Known Allergies
Please list any Medication Or Vitamins Your currently taking
Which of the following best describes your skin type
Sensitivity
Pustuals
Dryness
Facial Hair
Itchy eyes
Broken Capillaries
Redness
Underlying Congestion
Rosacea
Freckles
Flaking
Age Spots
Dehydration
Always Burns Easily Never Tans
Dull
Always Burns Tans Slightly
Fine Lines
Burns Moderately Tans Gradually
Wrikles
Seldom Burns
Oily T Zone
Always Tans Well
All Over Oilyness
Rarely Burns Deep Tan
Open Pores
Never Burns, Deeply Pigmented
Whiteheads
Dark Circles Around Eyes
Blackheads
What are your skincare goals?
What is your Skincare routine?
Cleanse
Tone
Moisturise
Exfoliate
Mask
None of above
What would you like to achieve from this treatment?
Have you ever had any chemical peels, laser or microdermabrasion with the last 2 weeks?
Yes
No
Any other concerns or requests?
Would you like to come in for a patch test PRIOR to your service?
(This is to avoid any negative reactions to the products.)
Yes
No
*If you answered, "No" to the question above then please initial under the statement on the line below.
I have been offer the patch test and respectfully decline. I do understand and accept the risk of an allergic reaction on the day of my appointment by declining to take the patch test.
Next
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
01
.
Registration
02
.
Consent & Waivers
Facial Registration & Consent Form
All of the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting my Esthetician to any physical or mental condition which would affect my service or results. I understand my treatment is therapeutic in nature and will alert my Esthetician to any discomfort.
Clear
Waiver.
I understand and acknowledge there are risks involved with the treatment of facials, peels, dermaplaning, microdermabrasion, microcurrent, electrical skin treatments, and waxing. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive A Day in Paris's and the Esthetician’s liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications, or effects and hereby waive A Day in Paris's and the Esthetician’s liability if such results or complications occur. In consideration for A Day in Paris and the Esthetician performing this procedure, I agree I will assume the risk and full responsibility for 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 is performed. I understand that the Esthetician does not diagnose illness, disease, or any other physical or mental conditions. Any sexual misconduct exhibited by the Client will result immediate and permanent termination of the session, and the client will be liable for payment of 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 the Esthetician, A Day in Paris, it’s service providers, owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. I agree this waiver and release shall 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 Covenant” not to sue A Day in Paris or any of it’s service providers.
Clear
MAXIMUM LIABILITY. A DAY IN PARIS'S MAXIMUM AGGREGATE LIABILITY TO PATIENT RELATED TO OR INCONNECTION WITH THE PROCEDURE PERFORMED BY A DAY IN PARIS, ITS EMPLOYEES, OR AGENTS WILL BE LIMITED TO THE TOTAL AMOUNT PAID TO A DAY IN PARIS BY PATIENT FOR THE PROCEDURE DESCRIBED IN THIS AUTHORIZATION AND CONSENT.
Signature
Clear
Name
Date
MM
/
DD
/
YYYY
IF YOU ARE UNDER 18, YOUR PARENT/GUARDIAN WILL NEED TO COMPLETE THIS SECTION.
Signature
Clear
Name
Date
MM
/
DD
/
YYYY
SEND
Please wait...
Previous
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20