Body Treatment | Beauty Esthetics By Diana Sanchez

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Body Treatment

Name *

Last Name *

Date of birth *

Age *

Gender *

Height *

Address *

City *

State *

Zip Code *

Phone *

Email *

Emergency contact *

Phone *

How did you hear about Beauty Esthetics? *

Do you have or have you had any of the following conditions? If yes, please select them:Alcohol abuseCancerDizzinessAsthmaSeizuresEpilepsyBronchialDiarrheaFood AllergiesConstipationEating DisorderGlaucomaDiabetesFatigueHeart DiseaseDrug AbuseGallbladder DisorderInsomniaFaintingHeadachesLiver DiseaseHigh CholesterolHypertensionMigrainesKidney DiseaseObesityLung DiseaseNervousnessThyroid DiseaseMoodinessEruptionsThyroidPalpitationsSleep ApneaCerebrovascular AccidentsArthritisAnemiaHemorrhagic DisorderDepression

Please indicate Yes or No to the following questions:

Are you currently (or possibly pregnant)? *YesNo

Do you have any metal in your body? *YesNo

If yes, please specify the area: *

Do you have any allergies or intolerances? *YesNo

If yes, please specify the area: *

Are you currently under the care of a doctor? *YesNo

If yes, please specify the area: *

Do you have any implants? *YesNo

If yes, please specify the area: *

Have you ever been treated with hormonal medications? *YesNo

If yes, please specify the area: *

Have you ever had any cosmetic/plastic surgery? *YesNo

If yes, please specify the area: *(include dates of medication/treatments).

Please list everything you are currently taking, concentration and frequency:

Prescription drugs *

Over-the-counter drugs *

Vitamins and other supplements *

Anything else you would like the esthetician to take into consideration?

Medical Consent *

I agree that all of the above medical information is true and complete. I agree to the privacy policy and terms and conditions.

Daily activity *

Sleep Hours *

Sport (what and how often) *

Do you smoke? *YesNo

Glasses of water per day *

How many meals per day do you eat? *

From 1 to 10, 1 being the worst and 10 being the best… How do you consider your diet to be? *

Tendency to depression? *

BODY TREATMENT CONSENTS

I have voluntarily chosen to undergo this treatment/procedure after the nature and purpose of this treatment, along with the risks and dangers involved, have been explained to me.

Although it is impossible to list all potential risks and complications, I have been informed of the possible benefits, risks and complications. I also acknowledge that there are no guaranteed results and that independent results depend on age, skin condition and lifestyle and that there is a possibility that I may need additional treatments on the treated areas to obtain the expected results for an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that you may have additional questions or concerns about my treatment or the suggested home product/post-treatment care, I will consult the esthetician immediately.

Also, to the best of my knowledge, I have provided an accurate description of my medical history, including any known allergies or prescription medications or products that I am currently ingesting or using topically.

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 satisfactorily 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 undisclosed at the time of this body procedure that may be affected by the treatment performed today.

PHOTO AND VIDEO AUTHORIZATION

I would like your permission to use these photos for advertising purposes. For example: portfolios, online and print ads, etc. Your consent is required in this regard. Please circle and indicate with your signature whether or not you would like your photos to be used in advertising. We also like to tag our clients in the photos used on our Instagram profile! Please indicate whether you would like to allow this or not.

Feel free to use them *YesNo

Please tag me on Instagram *YesNo