Bloomja Esthetics Client Consent Form

Client Consent Form

I hereby consent to and authorize Yasiri Gomez-Vazquez to perform the following procedure(s)/treatment(s): Choose treatments that will or could be performed on you. Check the box for YES, leave blank for NO.

First Name

Last Name

Address

Phone *

Email *

Intake Form Date *

Have you used any Retin A. Alpha Hydroxy, Accutane or any topicals in the past 72 hours? If so list them

If YES, list:

Are you allergic to anything? If so, please list:

Do you have any medical issues or concerns that should be noted before receiving treatment that could harm you or the provider? If so, please list:

Please list all medications that you are currently taking:

What concerns do you have regarding your skin or your body?

What improvements/goals would you like to see regarding your skin and/or body?

Do you allow "Before & After" photos to be taken?

Client Acknowledgment and Release

I understand that I am receiving a professional treatment(s): by Yasiri Gomez-Vazquez. I understand that I do not hold the owner/esthetician responsible for any accidents that may occur inside or outside the facility. I will notify the owner or service provider if I experience any reactions from the treatment(s) performed. If I have any questions or concerns I will contact the owner or service provider. I understand that no results are guaranteed and that there are no refunds.

Cancellation/Rescheduling Policy:

Cancellation: if for any reason you need to cancel or change your appointment, I ask out of consideration for both business and other clients, to please notify 48 hours prior to your scheduled appointment, and that you have confirmation from Yasiri Gomez-Vazquez that she has received the cancellation notice. I understand life gets hectic and things come up, however if you are unable to cancel your appointment or no show, there is a cancellation fee or a half booked service fee. There is a $20 deposit that is non-refundable. If something comes up and the appointment has to be rescheduled you will have a one-time change that will carry your deposit over to your new appointment.

Thank you for understanding and respecting the business and other clients.

-Bloomja Esthetics by Yasiri

Please sign below to acknowledge the above statement(s).

Clear

I agree to use electronic records and signatures

Address:
435 Hawthorne Ave, Athens, GA 30606

Call:

706-818-1780

Email: [email protected]