Name
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First Name
Last Name
Covid-19:
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Birthday (minor must cosign with an adult)
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MM
DD
YYYY
Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Phone #
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(###)
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Emergency Contact
First Name
Last Name
Emergency Contact Phone #
(###)
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Which is more important to happen on your service day?
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Relaxation
Treatment focus
What are your specific concerns/challenges with your skin?
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
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2. Have you had any health problems in the past or present?
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If "Yes"
3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.
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4. Check for "Yes"
5. Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?
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6. Have you ever experienced claustrophobia?
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7. Do you have any allergies?
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8. Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
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9. Have you use any of the following in the last 3 months?
10. Do you get Botox or fillers or injectable for cosmetic use?
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11. Do you wear contact lenses? (If you do wear contact lenses, IF it is possible, do not wear your contact lenses on the day of service.)
12. Where are your products from?
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13. What skin care products are you currently using and how religious of your routine?
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Hormone related questions:
Additional Question(s) / Message:
Found Us Through:
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-Select One-
LaTerre Flower Shop
E2 Yoga & Fitness
Flower Fantasy
Fresh Mequon Juice Bar
Scentsory Bath & Body Boutique
The Cheel
Friend (provide a name below)
Google
Other Search Engine
None of the above (provide detail below)
By checking this box, I believe all are true to the best of my knowledge.
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By checking this box, I understand pictures of my skin will be taken for progress documentation & educational use.
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I hereby consent to and authorize EnPey Ko to perform the following procedure:
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Microdermabrasion
Dermaplaning
Chemical Exfoliant/Peel
Body/ Facial Waxing
Skin Classic
Facial
I give permission to my therapist, EnPey Ko, to perform the procedure(s) stated above. We have discussed and will hold her harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over-the-counter or prescription medications that I use regularly and I am not presently using isotretinoin (Accutane). I have not had any facial surgical procedures or other chemical peels or skin treatments that I have not disclosed to my therapist. I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my therapist. I am over the age of eighteen (18) or I have approval of my guardian to receive my procedures. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated.
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I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by EnPey Ko.
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Although, it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.
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I understand the post-treatment home care instruction is important. I understand how important it is to follow all instructions given to me for post-treatment care. 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. If I don't follow as told, I will only hold myself accountable for failure to follow the program.
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I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.
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I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, whose signature appears below, 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.
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I DO NOT have a history of keloidal scarring, excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, or any other existing condition that may interfere with the positive outcome of this treatment.
I DO HAVE a history of whatever checked below or any other existing condition that I KNOW it/they may interfere with the positive outcome of this treatment or the speed of recovery time and progression of the outcome may be slower.
My expectations are realistic, and I understand that the results are not guaranteed.
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I agree that I am willing to follow recommendations by my esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible adverse reactions, including recognizing the importance of adhering to sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my esthetician, and I acknowledge that I have been informed of the possible negative reactions and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). If I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately.
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I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. 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 answer.
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I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. 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 answer.
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Today's Date
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MM
DD
YYYY
Guardian (You must be at least 18yrs of age):
Enter your name if you are a guardian for the name on top of this form Ever Beautiful or EnPey will not be held accountable for your home dispute among guardians of this minor.
First Name
Last Name
