CLIENT CONSENT, LIABILITY, & MEDICAL HISTORY FORM (e-Sign Form) I hereby consent to and authorize Metamorphosis Esthetics to perform the treatment. I have been given the option to contact her through email, phone, or text to choose the proper treatment I request performed. E-mail: sarah@metamorphosisesthetics.com Phone/Text: 916-836-5427
Name(Required)
First
Last
Address: (We can send products to your home)(Required)
How did you find us?(Required) Google Search Social Media Recommendation Link from another website Saw our Ad Other
Voluntary Election Terms (Please Read) I have voluntarily elected to undergo this treatment/procedure this treatment after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved by Metamorphosis Esthetics. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle, and that there is a possibility I may require further treatments of treated areas to obtain the expected results at an additional cost. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Sarah Bigornia immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently investing or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Metamorphosis Esthetics responsible for any of my conditions that were present, but not disclosed, at the time of this skincare procedure, which may be affected by the treatment performed today.
PHOTO AND VIDEO RELEASE(Required) Do you consent to Metamorphosis Esthetics using your before and after content for business purposes?
MEDICAL HISTORY Please fill out accurately and completely.
PLEASE FILL OUT ACCURATELY AND COMPLETELY Please fill out this form accurately so we may identify all extrinsic and internal factors. Choosing the correct treatment and products for your beautiful unique skin is vital. We want to offer you the maximum benefits of your skin, lash, or waxing journey with us. Thank you for choosing Metamorphosis Esthetics as your primary skin care provider.
What kind of skin do you consider yourself?(Required) Normal Oily Dry Sensitive Combination
Current stress level? (to identify hormones)(Required) please choose Low Medium High I'm stress free
How Often Do You Exercise?(Required) please choose 1-2 days per week 3-5 days per week Everyday Never
How Often Are You In The Sun?(Required) please choose 1-2 days per week 3-5 days per week Everyday
Do You Smoke(Required) please choose Yes No Trying to Quit Using patch or some other tobacco cessation method
If Yes to Smoking, How Often? please choose 1-2 days per week 3-5 days per week Everyday
Do You Drink Alcohol?(Required) please choose Yes No
If You Drink Alcohol, How Often? please choose 1-2 days per week 3-5 days per week Everyday
Any Medical Conditions?(Required) Please Choose Yes No
Pregnant or Trying to Get Pregnant?(Required) Please Choose Yes No
Are You Taking Birth Control?(Required) Please Choose Yes No
Do You or Have Experienced Any Cold Sores?(Required) Please Choose Yes No
Are You Taking Any Steroids?(Required) Please Choose Yes No
MEDICAL HISTORY CONTINUED (from above) Please Answer Using A Simple "Yes or No" Dropdown and then provide an explanation for "Yes" at the bottom.
Medical History Cont. (check all that apply) Medical History Cont. (check all that apply) Have You Been to A Tanning Salon?(Required) Please Choose Yes No
Please Explain a "Yes" Answer From Above
For Example, If You Answered Yes to Botox Above, Then Explain For What Reason (for cosmetic reasons or headaches as an example)
END MEDICAL HISTORY SECTION (from above)
SKIN ROUTINE How Often Do You Wash Your Face?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Exfolliate?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use Face Masks?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use Toner?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use Serums?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use Retinol?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use A Moisturizer?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use SPF?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
LASHES Do You Have Any Eye Conditions?(Required) please choose Yes No Not Sure
Do You Wear Glasses or Contacts?(Required) please choose Yes No
Allergies?(Required) HAIR REMOVAL In This Section Please Check Any Condition You Have Been Diagnosed with Recently or In The Past. This Includes Self-Observed or Diagnosed by A Clinical Physician.
Hair Removal (check all that apply) Hair Removal (check all that apply) Hair Removal (check all that apply) How Often Do You Shave?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
How Often Do You Use Wax?(Required) please select frequency everyday 1-3 times a week 4-6 times per week Never
BODY CONTOURING Are You Currently Menstruating?(Required) Please Choose Yes No
Have You Had Surgery Within Last 3-6 Months?(Required) Please Choose Yes No
Body Contouring (check all that apply) Body Contouring (check all that apply) Please State Any Questions or Concerns Before Treatment
I Certify My Medical History is Accurate and Current to The Best of My Knowledge. IMPORTANT: WITH YOUR SIGNATURE BELOW, YOU ARE CERTIFYING ALL INFORMATION IN THE CLIENT CONSENT AND MEDICAL HISTORY IS ACCURATE TO THE BEST OF YOUR KNOWLEDGE.
I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical and health conditions and to update on future visits. Current history is essential for the provider to execute appropriate treatment procedures. I accept arbitration as a means of resolution for practice liability.
CANCELLATION AND LATE POLICY PLEASE READ OUR CANCELLATION AND LATE POLICY BELOW.
Terms For Cancellations A Reservation fee is required (50% of the service fee) When booking online as a first-time client, all cancellations are required to be made within 24 hours or more of your scheduled appointment or will be charged as set forth below.
Same-day cancellation: the full amount of services will be charged.
No call, no shows: the full amount of services will be charged. If you are 10-15 minutes late or later we will do our best to accommodate. Time is of the essence. Anything over 15 mins, will be charged and you will have the option to reschedule.
I want all of my clients to know that I will schedule myself with 30 minutes in between each client. I am aware of unexpected obstacles and I want you to have your service done, it's a hassle to come back or rebook in general. I put that space in between because I may have a client before or after you and you are deserving of my fullest attention without rush or worry. I am here for you and I ask for the same in return.
Please feel free to email, call, or text my business phone at any time if you are running late.
E-mail: sarah@metamorphosisesthetics.com Business phone: 916-836-5427
IMPORTANT: PLEASE READ THE ABOVE TERMS FOR CANCELLATIONS TO AVOID BEING CHARGED FOR AN APPOINTMENT YOU DO NOT SHOW UP FOR.
Client Signature(Required) BY SIGNING BELOW: YOU ATTEST TO THE CLIENT CONSENT FORM AND MEDICAL HISTORY FORM AS FILLED OUT TO THE BEST OF YOUR KNOWLEDGE. YOU ALSO ATTEST TO READING, UNDERSTANDING, AND AGREEING TO OUR CLIENT CANCELLATION POLICY.
