CONSENT FORMS | My Site

Covid Form

**All forms will be filed and stored for your safety at the beginning of each service.

Screening Questions for COVID-19

Do you have any of the following?

□ Cough
□ Fever or chills
□ Shortness of breath or difficulty breathing
□ Fatigue
□ Muscle or body aches
□ Headache
□ New loss of taste or smell
□ Sore throat
□ Congestion or runny nose
□ Nausea or vomiting
□ Diarrhea

• Students who have symptoms of acute respiratory illness are recommended to notify their instructor and stay home until they are free of fever (100.4° F [38.0° C] or greater using an oral thermometer), have signs of a fever, and any other symptoms for at least 24 hours, without the use of fever-reducing or other symptom-altering medicines (e.g. cough suppressants).

Are you ill, or caring for someone who is ill?

Students who are well but who have a sick family member at home with COVID-19 should notify their school instructor.
If a student is confirmed to have COVID-19, the student should inform fellow students of their possible exposure to COVID-19 in the school setting but maintain confidentiality as required by the Americans with Disabilities Act (ADA).

In the last two weeks, did you:

□ Have contact with someone diagnosed with COVID-19?
□ Live in or visit a place where COVID-19 is spreading (apart from CA)?

If you have one or more symptom(s) that may be related to COVID-19 stay home and take care of yourself.

Cupping Form

NEW PATIENT INFORMATION:

Date: ____________________

Name: ________________________________________________________________

Age: _________ Date of Birth: _________/_________/___________

Address: _______________________________________________________________

City:_________________________ State: _____________ Zip: __________________

Phone Number: ___________________________________________

E-mail address: _________________________________________________________

Do you have epilepsy? Y N Are you pregnant? Y N

Have you ever had hepatitis? Y N Are you HIV positive? Y N

Are you taking blood thinners? Y N

EMERGENCY CONTACT:

Name: ____________________________Relationship: _______________________ Phone Number: _______________________________________________________

Primary Physician: _____________________________________________________ Phone Number: _______________________________________________________

Facial Consent Form

Esthetician Services Consent Form

THIS FORM MUST BE COMPLETED & SIGNED BEFORE RECEIVING A FACIAL. General & Medical Information

List any medications, supplements that you are currently taking: _______________________________________________________________________________________

What temperature of water do you cleanse with? ______________________________________________

Do you have any specific skin care problems / allergies pertaining to your face or body? _______________________________________________________________________________________

What skin care products do you currently use? ________________________________________________

Have you ever had chemical peel, laser, microdermabrasion, or any skin resurfacing treatments? If yes, when was your last treatment? __________________________________________________________________

Do you use Retin A, Renova, or Adapalene? ___________________________________________ Do you use acne medication? What kind? _____________________________________________

Do you burn easily? _______
Do you wear SPF? ______
Do you experience breakouts? ______
What are your skin care goals? ______________________________________________________

Do you experience an oily shine during the day? _______ Are you currently having your menstrual period? _______ Are you taking oral contraceptives? _______

If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which facial treatments are contraindicated.

Client Signature ________________________________________________ Date ______________________ NAME:___________________________________ PHONE:________________________________________ EMAIL:___________________________________ ESTHETICIAN’S NAME: ___________________________