Consent for Services
I, the undersigned, hereby consent to receive esthetic services provided by Speakeasy Beauty Bar and its licensed estheticians. I understand that the services provided may include: Facials, Chemical Peels, Waxing, Microdermabrasion Extractions, LED Light, High Frequency
☐ Other: ___________________________________
I understand that these treatments are not medical in nature and are not a substitute for medical examination, diagnosis, or treatment.
Medical History and Condition Disclosure
I agree to provide accurate and complete health information to the best of my knowledge. I confirm that I have disclosed any known allergies, sensitivities, skin conditions, or medications that may affect the outcome of the treatment.
Please answer the following: Do you have any of the following (check all that apply):☐ Active cold sore (herpes simplex)☐ Open wounds or skin infections☐ Severe acne or rosacea☐ Recent cosmetic procedures (e.g., Botox, fillers, laser)☐ Allergies to skincare ingredients or latex☐ Use of Accutane (within the last 6–12 months)☐ Pregnancy or nursing☐ Other medical conditions: _______________________________________
NOTE: If you have an active cold sore or any contagious condition, your appointment must be rescheduled. Services cannot be performed during an active outbreak.
Potential Risks and Side Effects
I understand that while every precaution will be taken to ensure my safety and comfort, there may be risks associated with esthetic treatments, including but not limited to:
Redness or irritation
Allergic reaction
Skin sensitivity or breakouts
Bruising, swelling, or discomfort
Temporary or permanent pigment changes (in rare cases)
I understand that results are not guaranteed and may vary depending on skin type, lifestyle, and adherence to aftercare instructions.
Aftercare Responsibility
I agree to follow all post-treatment care instructions provided by my esthetician. I understand that failure to follow these instructions may affect my results and increase the risk of adverse reactions.
Liability Release
I release and hold harmless Speakeasy Beauty Bar, its owners, employees, and contractors from any and all liability, claims, demands, or causes of action that may result from services rendered, including any damages, injuries, or complications that may occur.
I affirm that I am at least 18 years of age (or that a parent/guardian is signing below if under 18), and I am voluntarily receiving services with full understanding of the potential risks involved.
