Remedy Corrective Skin

First Name *

Last Name *

Email *

Phone *

Date of Birth (DOB) *

Address

City

State

Postal code

Emergency Contact *

How did you hear about us? *

Social Media

Google

Yelp

Friend/Family

List medications/supplements you are currently taking.

Any recent surgery, including plastic surgery?

Are you pregnant or trying to become pregnant?

Are you taking birth control pills?

Are you undergoing any hormone replacement therapy?

Your Lifestyle

What is your occupation

What is your sun exposure? *

Never

Light

Moderate

Exposure

Do you use sun protection (sunscreen, hats, protective clothing)? *

Yes

Do you use tanning beds? *

Yes

Do you smoke? *

Yes

Do you drink more than 4 caffeinated beverages a day? *

Yes

If you checked any Skin History, please explain

Are you currently using products containing any of the following ingredients?

Any history of previous facials, microdermabrasion, peels or other treatments?

How does your skin heal? *

Fast

Slow

Scars

Pigment

Do you get bruises easily? *

Yes

Have you ever used or been prescribed any acne medication?

Have you received Botox, Restylane, or Collagen injections in the last 6 months?

I have read and completed this questionnaire truthfully. I understand that withholdinginformation or providing inaccurate details about my medical history, allergies, medications, andskincare routines may lead to contraindications or adverse reactions to the treatments I undergo.I agree to inform the technician of any changes in the above information.

Client Consent *

I hereby consent to and authorize Remedy Corrective Skin to perform the following procedure: I have voluntarily chosen to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. While it's not possible to list every potential risk and complication, I've been informed about potential benefits, risks, and complications. I understand that results are not guaranteed and may vary based on factors like age, skin condition, and lifestyle. Additional treatments for expected results may be needed, incurring extra costs. I have read and understood 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 I may have additional questions or concerns regarding my treatment or suggested home post-treatment care, I will consult the esthetician immediately. I have also, to the best of my knowledge, provided an accurate account of my medical history, including any known allergies and current use of prescription drugs or topical products. I consent to the use of photographs for treatment documentation purposes, with all personal information kept confidential. I have read and fully understand this consent agreement and all of my questions have been answered to my satisfaction. I hereby give my full consent to the procedure and subsequent treatments, releasing Remedy Corrective Skin and associates from any liability related to it.

Photo & Video Release Form *

I, the undersigned client, hereby grant and authorize Remedy Corrective Skin the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, videos and /or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print and digital communications, without payment or any other consideration. This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered. I waive any rights to royalties or other compensation arising or related to the use of the photograph or recording. I understand and agree that these materials shall become the property of Remedy Corrective Skin and will not be returned. I hereby hold harmless and release Remedy Corrective Skin from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate. By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement.

Cancellation Policy *

Our goal is to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy. Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables us to better utilize available appointments for our clients. At the time of booking your appointment you will be asked to pay a [YOUR AMOUNT] deposit that will be credited towards your treatment/s. Time has been specifically reserved for your appointment, procedure, or treatment. If you need to cancel or reschedule your appointment you must call at least 24 hours prior to your appointment and your deposit will either be refunded or pushed for a future appointment. However, providing less than 24 hours’ notice will require you to pay a [YOUR AMOUNT] cancellation fee. If you arrive more than 15 minutes late for your appointment it is considered a no-show and you will be charged the cancellation fee. We are happy to answer any questions regarding this cancellation policy. I have read and fully understand the above Appointment Cancellation Policy and agree to be bound by its terms. I agree to pay the cancellation fee in the event of a missed appointment.

Signature *

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Before you book any service, please fill out our Intake Form.

Filling these forms out before your appointment is required.