Consent

Consent Form

 

for Brazilia

Please complete the form below. All fields are required.

CONSENT FORM

WARNING: Brazilia Staff will not preform Facial Waxing treatments on Clients using Medical Grade Skin Care Products.
Please notify your Esthetician if you have any known allergies or sensitivities, if you are using any of the following: Accutane, Tretinion, Retin-A, Any Medical Grade Skin Care products, acne specific medication, currently using Antibiotics, or if you are Diabetic or Pregnant.

Waxing:

Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result ftrom this treatment. I have given an accurate account of known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Skin Care, Facials and Peels:
Please note that certain skin care treatments can have side effects such as immediate pinkness, rosy tone or “sun burn” appearance, tightness, peeling, flaking, swelling, tenderness, dryness or itchiness etc.

Massage: Brazilia Skin Care hires licensed and separately insured independent contractors to administer Massage Therapy treatments.

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the skin care procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

I agree to the terms and policies of the consent form above.
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