CONSULTATION / CONSENT FORM
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Phone Number: ______________________________ Cel Number: __________________________
Email: ___________________________________________________________________________
Date of Birth: ______________________________________________________________________
Referred by: ______________________________________________________________________
Contraindications: (tick where appropriate)
Any form of infection, disease or fever Cancer Hypersensitive skin High Blood Pressure Epilepsy Recent surgery (last 5 years) Diabetes Varicose Veins Bruise Easily Pacemaker/Metal Implants Allergies HIV/Hepatitis Arthritis/Joint Pain Pregnancy
Have you had chemical peels, laser, microdermabrasion or any resurfacing treatments? Yes No
Do you use Accutane, Retin A, Renova, Salicylic Acid; Beta/Alpha Hydroxyacids? Yes No
If you have checked any of the above, please explain: _____________________________________
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For all waxing services please note that, for best results, the area should not have been shaved or waxed for at least 3 weeks prior to your appointment. I understand that the massage and facial services I receive are provided for the basic purpose of relaxation and relief of muscular tension. 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 the massage/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 spa 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 also understand that the Certified Esthetician reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which facial, massage or waxing treatments are contraindicated. This information is confidential and will not be passed onto a third party. Please sign below to confirm that all information is, as of date, accurate.
X ____________________________________________ Date _______________________________
Cause Mapping is a Root Cause Analysis method that captures basic cause-and-effect relationships supported with evidence. Cause Map Increased risk of heart attacks, stroke deathTwo thirds of diabetics die of heart problems; Masked test results increase risk of heart disease Problem Solving • Incident Investigation • Root Cause AnalysisDrug originally licensed with warning about ris
Annex to ISO/IEC 17025 declaration of accreditation for registration number: L 234 of Handelslaboratorium v/h Dr. A. Verwey Rotterdam This annex is valid from: 28-01-2013 to 01-01-2017 Replaces annex dated: 19-12-2012 Rotterdam, Vlaardingen, Pernis and Oosterhout Material or product Type of activity Internal reference Sampling Sampling for the anal
CONSULTATION / CONSENT FORM