Request Waiver

Because We Care

Please fill out this form to request a waiver at Facial Lounge. We love helping those in need.

Full Name (required)


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Work


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Referred By


Sensitivities or Allergies


Medications that you take regularly, including hormones, vitamins, etc.

Please check any health conditions which you have had or are now experiencing:


Do you have any metal implants in your body other than fillings (such as a pacemaker, pins and/or rods in bones or Copper IUDYesNo

Have you ever under gone treatments from a dermatologist?YesNo

Have you undergone any of these?:


Is there a history of acne in your family? YesNo

Do you smoke?YesNo

Do you use tanning booths?YesNo

Are you using Retin A?YesNo

How much sun exposure do you get a day?

What is your specific concern with your skin?


Have you received corrective skin care treatments before?YesNo

INFORMED CONSENT

Microdermabrasion is a treatment that projects a flow of inert crystals over the skin and abrades away epidermal tissue in the areas treated. Microdermabrasion is used to treat acne scar, wrinkles. After treatment, the skin may feel tight as if expose to the sun or wind. Any time the skin barrier is broken, there is a small risk of bacterial or viral infection. If you have a history of cold sores/herpes infections around the mouth or face, please inform the technician before your treatment. Eye lash tints and Eye lash extensions may result in minor irritations or cause damage to eye lashes. I acknowledge that no guarantee has been given and that there is a small percentage of patients who may experience mild skin eruptions following treatment. Dermaplaning can cause skin irritation. I understand the risk associated with the use of steam rooms, saunas and showers including slips and falls, and very rare instances heart attack or death. I understand the importance in discussing my treatments and the use of steam and infrared saunas with my Physician and take responsibility to do so.

BY SUBMITTING THIS FORM, I AGREE TO THE TREATMENTS BEING RECOMMENDED AND AGREE TO ASSUME ITS ASSOCIATED RISK. I HEREBY GIVE CONSENT TO THE ESTHETICIAN AND FACIAL LOUNGE DBA SHAPE-UP DAY SPA TO PERFORM MY TREATMENTS.

Client acknowledges and agree to hold Facial Lounge, Amber Johnson, Elle Were, Morgan Hartman and Lindsay Bowman harmless against any and all liability and claims for any injuries or any other occurrences of events directly caused by the active negligence for Microdermabrasion or Dermaplaning.

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