Facial - Consent Form
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, facials be contraindicated. A referral from your primary care provider may be required prior to the service being provided.
Choose Yes or No as it applies. If you answer “yes” to any of the following questions, please explain as clearly as possible.
I understand the service(s) may require multiple treatments for positive results. The total number of treatments may vary between individuals. Some individuals may not respond to treatment. The services rendered to me at Sheva Thai Spa are elective cosmetic services that may be performed by an esthetician. It is my responsibility to contact a physician directly with any questions I may have about my skin or health. I acknowledge that pre-service and post-service instructions have been discussed with me and that I understand all such instructions. The elected service specified above, as well as alternative service options and the potential benefits and risks of each have been explained to my satisfaction. I have had all my questions answered. I understand the requested and specified service(s) and accept the risks. I hereby release Sheva Thai Sap from any and all injuries, actions, causes of action, suits, damages, judgments, claims, and demands whatsoever, in law or equity, which I shall or may have, for, upon, or by reason of the performance or non-performance of the above indicated services. Because facial should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s and Sheva Thai Spa’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment.
Consent to treatment of a minor (if applicable): By my signature below, I hereby authorize Sheva Spa to administer facial techniques to my child as they deem necessary.