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Facial Intake and Waiver Form (New Client)

Please fill out this form to apply for membership.

Date of birth (optional)
Month
Day
Year
Do you have any of the following conditions?
Rosacea
Psoriasis
Heart Condition
Pacemaker
Epilepsy
Active Cancer
History of Cancer
Autoimmune Disease
High Blood Pressure
Diabetes
Other
Are you pregnant, breastfeeding, or trying?
Do you have any allergies?
Yes (please list)
No
Have you had any of these treatments within the last 30 days?
Botox/Filler
Laser Treatment
Dermatological Treatment
Chemical Peel
Microneedling
Dermaplaning
Other
Have you had any facial hair removal in the last 24 hours? (including shaving)
Yes
No

Please read and sign below:

I understand that the facial treatments provided by Kayla Kayser are for relaxation and skincare purposes only. They are not a substitute for medical treatment. I acknowledge that:

  1. The esthetician will perform a skin analysis to customize my treatment based on my needs and goals.

  2. I have disclosed all relevant medical and skincare history, and I take full responsibility for any reactions that may occur due to omitted information.

  3. I consent to the use of skincare products and equipment, including high-frequency, LED therapy, extractions, and oxygen therapy, based on my selected treatment.

  4. I understand that while facials are beneficial, results may vary, and no guarantees can be made regarding specific outcomes.

  5. I agree to follow post-care instructions provided by my esthetician.

  6. I release Kayla Kayser from any liability for undesired outcomes, including allergic reactions, skin irritation, or breakouts that may occur as a result of the treatment.

  7. I agree to notify my esthetician if I experience discomfort during the session and understand that I can request modifications or stop the treatment at any time.

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Contraindications

Please review this list of situations that may affect your facial:


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