Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Today's Date
*
MM
DD
YYYY
Gender Identity
Preferred Pronouns
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mobile Phone
*
(###)
###
####
Home Phone
(###)
###
####
Email
*
How did you hear about us?
What is the reason for your visit today?
What areas of concern and/or interest do you have regarding your skin?
If you are under the care of a physician, please describe.
Please list any prescription medications you are taking.
Please list any supplements you are taking.
Do you wear contacts?
If you recently received a chemical or AHA peel, what was the date?
Because hormones have a significant affect on the skin, it is important for us to know if you are undergoing any type of hormone therapy. This would include HRT, oral contraceptives, bio-identical hormones, gender affirming hormone therapy, or natural hormone supplements. Please list any hormone therapies you are receiving.
Are you pregnant, lactating, trying to become pregnant, other?
Do you smoke?
If you are on a special diet, please explain.
Have you ever used Accutane?
Have you ever used any form of retinol including Retin-A, Tazarac, Differin, or Renova?
Are you currently using products that contain glycolic acid, salicylic acid, or lactic acid (AHAs/BHAs) or Hydroquinone?
If you have any allergies or sensitivities to food, cosmetics, or drugs, please explain.
Please check any of the items you are currently experienced or have experienced in the past.
Please list any other health concerns you have.
Leah Nickie Advanced Aesthetics, LLC Treatment Consent and Release of Liability
*
I acknowledge that beauty and medi spa treatments, including, but not limited to: skin care, massage, microablation, microdermabrasion, waxing, hair and scalp treatments, nail treatments, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, PRP Injections, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.
On behalf of myself, my heirs, my executors, and my administrators, I understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, skin damage, nerve damage, disability, death, scarring, infection, change in skin pigmentation, allergic reaction, eye damage, change or damage to my vision, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.
Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, indemnify, hold harmless and release from any and all liability, costs of litigation and any other costs of every kind and nature, the company and the individual that provided my treatment, the insured, their insurance company, and any additional insureds, as well as any officers, directors, or employees of the above companies for any injury, property damage, condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.
The release contained herein will be construed to apply to the greatest extent permitted by law and, if permitted by law, will apply even if any such injury or damage is caused in whole or in part by the released parties' own negligence or the negligence or willful conduct of any other individual.
In the event any provision of this agreement is found to be legally invalid or unenforceable for any reason, all remaining provisions will remain in full force and effect. In the event any provision of this document is found by a court of competent jurisdiction to exceed the limits permitted by any applicable law or to be invalid or unenforceable as written, such court (s) may exercise its discretion in reforming such provision(s) to the extent necessary to make it reasonable and enforceable.
The undersigned waives, to the fullest extent permitted by law, any right they may have to a trial by jury in any legal proceeding directly or indirectly arising out of or relating to this agreement whether based in contract, tort, statute (including any federal or state statute, law, ordinance, or regulation), or any other legal theory.
The insured agrees that this contract will be governed and construed in accordance with the laws of the state of South Dakota and that all actions of any kind whatsoever will be filed, heard, governed, arbitrated, and restricted to the venue of the County of Meade County, South Dakota. The undersigned also agrees and stipulates that they will be responsible for any legal, or other costs of any kind incurred by the insured or their insurance company in defense of this agreement should the undersigned challenge its enforceability.
The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature the insured, and their insurance company for the transmission of any disease, condition, injury or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured's location or the location of treatment.
I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment.
AGREEMENT By signing below, Client agrees and acknowledges to all of the terms and conditions contained herein.
*
Please type Client name below.
First Name
Last Name
Parent/Guardian Name if Client is Under 18
THE UNDERSIGNED PARENT AND/OR GUARDIAN HEREBY CERTIFIES THAT: (1) I AM A PARENT/GUARDIAN OF THE CLIENT; (2) I HAVE LEGAL RESPONSIBILITY OVER THE CLIENT; (3) MY SIGNATURE IS SUFFICIENT TO CONSENT TO THE PARTICIPATION OF THE CLIENT IN THE SERVICES AND TO ENTER INTO THIS RELEASE FOR AND ON BEHALF OF THE CLIENT; (4) I HAVE COMPLETELY READ AND UNDERSTAND THIS RELEASE AND ITS TERMS; (5) I AM AWARE, BY SIGNING THIS RELEASE I ASSUME ALL RISKS AND WAIVE AND RELEASE CERTAIN RIGHTS THAT I, THE CLIENT AND EACH OF OUR HEIRS, NEXT OF KIN, FAMILY, RELATIVES, GUARDIANS, CONSERVATORS, EXECUTORS, ADMINISTRATORS, TRUSTEES AND ASSIGNS MAY HAVE AGAINST RELEASEES.
First Name
Last Name
Today's Date
MM
DD
YYYY
