consent formsIf you are a new client, please fill out the appropriate consent form forthe service you are booking. Thank you! NEW CLIENT FORM New Client Form GENERAL Name * First Name Last Name Date * MM DD YYYY Email * Phone Number * (###) ### #### I prefer to be contacted via: * Text Email Date of Birth * What concerns do you have regarding your skin? Please select all that apply. * Acne/Breakouts Blackheads/Whiteheads Broken Capillaries Dark Clogged Pores Dark Spots Dryness Oily Skin Redness Rosacea Sun Damage Scarring Wrinkles/Fine Lines Uneven Skin Tone Other How many ounces of water do you drink daily? * Is this your first skincare treatment? * Yes No MEDICAL HISTORY Do you sunburn easily? * Always Usually Sometimes Rarely Never Do you use sun protection? * Yes No Do you have allergies? * Yes No If yes, what are you allergic to? Do you currently or have you had any of the following? * Acne Abrasions Arthritis Autoimmune Disease Broken Capillaries Bleeding Disorder Dermatitis Depression Diabetes Eczema Epilepsy Fever Blisters Heart Condition Hepatitis High Blood Pressure HIV Hypopigmentation Hyperpigmentation Insomnia Low Blood Pressure Lupus Sinus Infection Surgery (recently) Pregnant Psoriasis Seborrhea (dandruff) Shingles Skin Cancer Warts Other Are you currently taking any medication? * Yes No If yes, please list any medications you are on: Have you used Retin-A, Renova, AHA’s or Retinol/Vitamin A products in the past 3 months? * Yes No If yes, please explain: Have you received Botox, Restylane, or filler injections in the last 6 months? * Yes No Have you received Botox, Restylane, or filler injections in the last 6 months? * Yes No If yes, please explain: What type of skin do you have? * Oily Dry Dehydrated Normal Combination Not Sure WAX SERVICE Have you ever had a reaction to a waxing service? * Yes No If yes, please explain: Do you use Glycolic Acid, Salicylic Acid, Lactic Acid or any other acid- based products on * Yes No If yes, please list: Are you taking acne medication or vitamin-A products? * Yes No If yes, please list: Have you had microdermabrasion, laser resurfacing or injectable fillers recently? * Yes No If yes, please explain: Treatment areas we are targeting: * Brows Upper Lip Other AGREEMENTS By checking this box, I grant permission Cara Luna Skincare/Luna Skincare Lounge to take photographs, videos, or other media for use in advertising, social media, website and other advertising. I hereby waive any right to inspect or approve thefinished photographs now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. Initials. I am at least 18 years of age and am competent to contract in my own name. I have read this release before signing below, and fully understand the contents, meaning, and impact of this release. I understand that 1 am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I accept By checking this box, I agree to the following statements: * If I experience any pain or discomfort during the session, I will immediately inform the aesthetician, so the products and/or technique may be adjusted to my level of comfort. I further understand that facials should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that aestheticians are not qualified to perform, 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 affirm that I have stated all my known medical conditions, allergies, and have answered all questions honestly. I agree to keep the aesthetician updated as to any changes in medical profile during the session and understand that there shall be no liability on the aestheticians part should I fail to do so. I also understand that the licensed aesthetician reserves the right to refuse service/treatments on anyone whom he/she deems to have a condition for which facial treatments/service are contradicted. I agree Thank you for submitting the form - I’ll be in contact soon! HYDROLUXX FACIAL TREATMENT HYDROLUXX FACIAL TREATMENT GENERAL Name * First Name Last Name Date * MM DD YYYY Email * Phone Number * (###) ### #### I prefer to be contacted via: * Text Email Services may be postponed if any of the following apply to you: -Botox or Drysport injections within the past two weeks -Accutane -Any facial waxing within the past 7 days (not including eyebrow wax) -Cancer or cancer treatments -Active skin abrasions or lesions -Retin A within the past 7 days of treatment -Blood thinner medication -Laser procedure within the past 2 weeks -Chemical peel within the past 2 weeks -Skin bleaching creams -Viral Infection/influenza/cold sore Services may still be performed at the Estheticians discretion: -Autoimmune Disease, Lupus, HIV, Epilepsy, or Hepatitis -Allergies -Eczema/ Psoriasis -Diabetes -Injections or Fillers within the past 2 weeks -Epilepsy -High/Low Blood Pressure -Lymphatic Disorder -Steroid injections/Cortisone -Thyroid Condition -Rosacea -Stage 3/4 acne -Under Medical Care Have you recently used? * Accutane Topical Medication Antibiotics Aesthetic Fillers Laser Treatments Other None AGREEMENTS The Zemits DERMELUXX is a non-invasive fluid dermabrasion treatment. The unique vaccum powered exfoliation applicator pulls in the skin tissue to clean and deliver active serums due to skin type and condition, the oxygen handpiece delivers serums to the skin, and the cooling wand soothes the skin. By checking this box, I agree with the following statements: * I have read the Dermeluxx Treatment Information & instructions. I have had an opportunity to ask questions about the procedure & treatment. The Dermeluxx Treatment cost has been discussed with me & I agree to pay this amount. I duly authorize Cara Luna Skincare to preform Zemits Dermeluxx Facial. I agree By checking this box, I understand that: * The goal of DERMELUXX Facial is to hydrate and deeply cleanse the facial skin, which will improve cases of texture, uneven skintone, acne and acne scarring, and overall health of the skin. Every person is unique, which means skin condition and results may vary. This makes it difficult to pinpoint an exact number of treatments that will be needed. Results may vary from individual to individual and amount of acne as well as amount of sun exposure also effect results. DERMELUXX Facial treatments are recommended every one to two months, depending on the skin type and condition for optimal results. DERMELUXX Facial may be performed any time before special events. Slight pink or redness to the skin is normal and typically subsides within a few hours of finishing the treatment. Skin irritation, bruising, or worsening of breakouts is an uncommon side effect, but may occur. Not often, allergic reactions such as hyperpigmentation, hypopigmentation, occur potential may beingpossibility can occur post-treatment. As any treatment, there may be unknown risks as of now. I agree By checking this box, I fully understand the effects explained to me: * After Dermeluxx Facial treatment, its possible to feel slight irritation, tightness, and/or redness. These are all common reactions which typically resolve themselves within 48-72 hours post-treatment. You may experience the following sensations within a few hours after Dermeluxx Facial: irritation in the area that's been treated. As every individual's experience is different, some clients may experience these symptoms delayed. The majority of Dermeluxx Facial clients can see immediate results after their treatment. Skin may feel hydrated and supple for a few weeks depending on proper at-home maintenance care. After a Dermeluxx Facial Treatment, the skin needs to be protected from UV rays and possible sun damage. Please avoid excessive sun exposure and use at least a SPF 40 sunscreen. I agree By checking this box, I acknowledge the following: * It is my responsibility to avoid waxing, lasers, aggressive exfoliation, and products containing and retinoids or glycolic acids on the treatment area for at least 2 weeks prior and post treatment. I will inform the Esthetician of any medical changes during the course of my treatment. Risk of side effects increase with immunocomprimised conditions such as HIV, Diabetes, Lupus or being on immunosuppresant medication which can increase risk of infection and improper healing. I do not have any of these conditions. I agree By checking this box, I agree with the following: I consent to Cara Luna Skincare/ Luna Skincare Lounge to take my photograph or video before, after and during my treatment to be anonymously used for advertising, social media, website and other marketing uses. I waive any right to royalties or other compensation aarising from the use of the image. I agree Thank you for submitting the form - I’ll be in contact soon! LASH LIFT FORM LASH LIFT FORM GENERAL Name * First Name Last Name Date * MM DD YYYY Email * Phone Number * (###) ### #### I prefer to be contacted via: * Text Email Date of Birth * HISTORY Have you ever used hair dye before? * Yes No Have you ever had an allergic reaction to hair dye? * Yes No If yes, explain: Have you ever previously had your eyebrows or eyelashes dyed or permed? * Yes No If yes, when? Did you experience any adverse reactions? * Yes No If yes, explain: Do you wear contact lenses? * Yes No Did you bring contact solution & a case with you today? * Yes No Do you have diabetes or any autoimmune disease? * Yes No If yes, explain: Are you currently being treated by a physician for any illness, virus, infection or condition? * Yes No If yes, explain: Please list any medications you are taking including over the counter, herbs and vitamins. * Do you have any allergies or sensitivities? * Yes No If yes, explain: Do you have any skin conditions? * Yes No If yes, explain: Are you pregnant? * Yes No AGREEMENTS *Although every precaution will be taken to ensure your safety and well-being , before, during and after your service it is important that you aware of the possible risks listed below. By checking this box, I agree with the following statements: * I understand that I must tell my technician immediately if I notice any sensation (good or bad) in the area of service. I understand that if I am pregnant I should not have any chemical service for the duration of my pregnancy, however it is my choice to do so. I consent to a 24 hour patch test. I understand that tinting eyelashes or eyebrows offers a risk of irritation to the eye and orbital eye area that could result in stinging or burning, blurry vision and potentially blindness should the dye enter the eye. I understand that if the hair dye, developer, perm solutions or mixture thereof accidentally comes in contact with my eye, it will be flushes with water and that I may need medical attention at my cost. I understand that some irritation, itching, or burning may occur to the skin which comes into contact with the products used for these service(s). I understand that there may be some residual dark staining left on the skin following the tinting process; this will fade and disappear within a short amount of time. I understand that while every attempt will be made to provide me with my chosen result that hair can absorb dye differently and my final result may not be the color I initially requested. I understand that over the course of several weeks, the tint will gradually lighten and fade & that if I use exfoliating/other ingredients on these areas or if I swim in chlorinated water the results of the service(s) will fade faster. Touch-ups will be required to keep the tint color looking fresh (3-4 weeks). I agree By checking this box, I agree to the following statement: * I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks and agree to keep my eves closed at all times unless otherwise instructed to do SO. I have accurately answered the questions above, including listing all known maladies, allergies, prescription drugs or products I am currently ingesting or using topically. I understand that my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event that I may have additional questions or concerns regarding my treatment, I will consult the technician immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I give permission to the technician to perform the service(s) we have discussed and I will hold them, the salon and its staff harmless from any liability that may result from this service(s I will not hold the technician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure, which may be affected by the treatment performed today. I agree PATCH TEST By checking this box, I agree to the following statement: * I confirm that a dye patch test was carried out and that I have been informed that I will need to check the area for 24 to 48 hours to ensure that no redness, itching, swelling or blistering has occurred. If any of these reactions do occur I will gently but thoroughly wash the test area with soap and warm water, rinse the area with cool water and then pat the area dry. I will then inform the technician as soon as possible and relay any and all information regarding the reaction(s) that occurred. I DID react - do not proceed with the service(s) I DID NOT react - I consent to proceed with the following service(s) and I accept full responsibility for any reaction which may occur. I consent to proceed with the following service(s) and I accept full responsibility for any reaction which may occur. Eyelash Tinting Eyebrow Tinting Eyelash Lift Eyebrow Lamination PATCH TEST REFUSAL I understand that a skin or other patch test may determine if I will have a reaction to the products tested within 24 to 48 hours, however | waive my option to a Patch Test and wish to proceed with the following services: Eyelash Tinting Eyebrow Tinting Eyelash Lift Eyebrow Lamination Thank you for submitting the form - I’ll be in contact soon!
