Client Consent & Liability Release

Esthetic Services Consent and Liability Release Form

First Name *

Last Name *

Phone *

Email *

Address

Street Address

City

State

Postal Code

Date of birth *

Do not insert manually

Welcome to Dermax Spa, we’re delighted you have chosen our aesthetic services. Certain spa services should not be performed under certain medical conditions; it is your responsibility to inform the Esthetician of any pre-existing conditions, limitations, or specific sensitivities and to inform your Esthetician if you feel any discomfort during the session. If you do experience discomfort, please tell your Esthetician to adjust the level of pressure. You understand and voluntarily accept any risk which you have been advised associated with your facial or any use of the company’s facilities, and hereby release Dermax Spa (including its employees, practitioners, agents, and insurers) from all liability for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you resulting therefrom any such injury or damage resulting from your failure to disclose any pre-existing condition, limitation or specific sensitivities, or your failure to inform your Esthetician of any discomfort during the session. Your Esthetician may determine that it is unsafe for you to proceed with or continue a session due to health-related concerns. In this event, you may be required to provide Dermax Spa with a physician’s medical release before continuing treatment.

The undersigned acknowledges that he /she has read the agreement.

What are your skincare goals?

What would you rate your skins current condition on a 1-10 scale ? (1 bad, 10 superb)

How committed are you to improving your skin on a scale of 1-10? (1 not at all 10 very)

Are you allergic to any products or ingredients? If so, please list:

General & Medical Information

Please check "Yes" or "No" to the Following Questions:

Are you pregnant? *

Yes

If Yes, how many months?

Any Recent Surgery? *

Yes

If Yes, What and When?

Are you taking any Medications? *

Yes

If Yes, Please list:

Are you taking Accutane? *

Yes

Do you have Rosacea? *

Yes

Are you using any Topical Medications? *

Yes

Are you using Retinoids? *

Yes

Are you using any exfoliating Acids? *

Yes

If Yes, which ones?

Have you ever had an adverse reaction to a cosmetic product? *

Yes

If Yes, which cosmetic product?

Have you had filler or Botox in the last 2 weeks? *

Yes

Do you currently have a pace maker or anything that would prevent you from Radio Frequency Treatments? *

Yes

Please explain in detail anything checked above:

Any other conditions not listed above?

Client Consent and Liability Acknowledgment

This form has no expiration date and shall serve as consent and confirmation for all current and future treatments performed at Dermax Spa. The client is responsible for notifying Dermax Spa and their esthetician of any changes to their health, medications, or conditions that differ from those stated in this form.

By signing below, I acknowledge that all the information I have provided is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in injury or adverse effects during or after services. I accept full responsibility for the accuracy of the information shared and release Dermax Spa and its staff from any liability arising from incorrect or false information provided.

Customer Signature *

Clear

By providing your phone number, you agree to receive recurring automated marketing and informational text messages and phone calls from Dermax. You understand that calls may be generated using automated technology, pre-recorded messages, or an AI voice. Consent is not a condition of purchase. Message and data rates may apply. You can opt out at any time by replying STOP to texts or requesting to be placed on our do-not-call list during any call