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Informed Consent to Service


I understand that facial services are not a substitute for medical care. I will seek medical care (at my expense) and contact my aesthetician immediately if an allergic or adverse reaction occurs.

I understand that my aesthetician will inform me what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. In order to receive maximum benefits from facial services, more than one application may be required. A series of treatments may be recommended and customized based on the advice of my aesthetician.

I understand that the rate of improvement from facial services depends on my age, skin type and skin concern. This includes, but is not limited to, the degree of environmental damage incurred, pigmentation levels, or acne condition.

I will follow pre- and post- facial treatment instructions and maintain appointment schedules as they are recommended. This includes the application of home care and taking the proper measures to help prevent sun exposure/damage.

I acknowledge that no guarantee has been made about the results of the facial service. I have been informed of some possible benefits, risks and complications which may include, but are not limited to, softer skin texture, reduction in the appearance of lines and wrinkles, reduction in acne lesions, swelling and redness, scabbing, peeling or sloughing, prolonged sensitivity to the environment and sun exposure, and increased or decreased pigmentation.

I understand that there may be a chance of discomfort during the facial service and there is a minimal risk of permanent skin damage.

I agree to inform my aesthetician of any changes in my health, prescription medications (topical and oral), and skin care regimen changes during the course of treatment.

(Women) I am not pregnant or nursing, or trying to conceive a child.

I have not used Accutane (or like prescription) ever or within the last 12 months.


I understand that waxing services could have unfavorable results including, but not limited to allergic reaction, irritation, stinging, burning, redness, soreness, bruising, etc.

I am aware that certain topical and oral medications can increase the risk of injury when combined with skin care and waxing services. I have fully and honestly disclosed all topical and oral medications that I have been and are using. I hereby confirm that I am not using any medication that could increase a risk of injury for myself and will notify the technician of any changes in my topical and oral medications in the future.

I understand that there are often inherent risks associated with waxing services and I agree that, as a condition of providing these services on an ongoing basis, I will not hold this facility responsible for unfavorable outcomes or results.


I am aware that there are risks associated with hair color services, including, but not limited to, an allergic reaction, irritation, burning, redness, etc. I will seek medical care (at my expense) and contact my stylist immediately if an allergic or adverse reaction occurs.


I understand that the massage I receive is 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 therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, 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. I understand that the License Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.

I affirm that I have/will state all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile during today’s and all future sessions, and understand that there shall be no liability on the massage therapist’s part should I fail to do so.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

I am aware that the massage therapist is not an employee of Skin Rejuvenation Clinique, Inc. but is an independent contractor.


I understand eyelash extensions require ongoing maintenance and that fill fees are based on time and/or the number of extensions that need to be replaced at fill appointments. If I wait too long between fills, I may need to pay for a new set. If I no longer wish to wear eyelash extensions, my technician will remove them for a minimal fee, I will not try to remove them myself.

Sleeping on my face, extreme weather changes, steam, sauna, and other activities may damage the adhesive or crimp the extensions and may require more frequent refills. I have reviewed and understand the aftercare instructions and will do my part to help maintain my eyelash extensions.

I understand that lash extension services and lash lift services have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the adhesive enter the eye or should an allergic reaction occur. Some irritation, itching or burning may occur on the skin if the bonding agent comes into contact with it. If the bonding agent comes into contact with my eye, my eye will be flushed with water and I will be assisted in seeking medical attention immediately.