Disclaimer/Consent Form | The Gua Sha Facial

Consent Form/Disclaimer for All facial/facial treatments.

* Please type in all information below. Read the Disclaimer/Consent form. If you have any questions, please contact me via email me. Click on the 'Contact' button in the heading.

Type in your Full Name.

Today's Date:

Type in your home address, with City, State and Zip Code.

Cell phone # :

Email Address:

General & Medical Information:

List any medications/supplements that you are currently taking:

Any specific skin care problems/allergies/ pertaining to your face or body? If so, whay are they?

Have you ever had a chemical peel, laser treatment, microdermabrasion, or any skin resurfacing treatments? If so, when?

Do you use any Retinol products? If so, what products?

Do you use acne medication, topically or orally? If so what kind?

Do you burn easily in the sun? Do you wear an SPF when you are outdoors?

Do you experience an oily shine during the day? If so, on what part of the face does ths usually occur?

Do you experience facial dryness? If so, on what part of the face does this usually occur?

Do you experience skin breakouts? If so, please explain.

What are your skin care goals? What would you like to achieve with The Gua Sha Facial treatment/service that you purchased?

Consent / Disclaimer

If I experience any pain or discomfort during the session, I will immediately inform the facial practitioner (Darlene McDowell) so that the products and/or technique may be adjusted to my level of comfort.

I further understand that The Gua Sha Facial, All Facials/Treatments, which can include Radio Frequency, Cold Laser, High Frequency Treatments, Microdermabrasion, Hydra Facial, Dermaplaning, Oxygen Facial, No Needle Mesotherapy, Red Light (Photobiomodulation) Therapy and any/all facial or facial treatment agreed by the client and practitioner, should not be construed as a substitute for medical examination, diagnosis, or treatment. The facial services are not intended to treat, cure or prevent disease.

Because certain treatments 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 facial practitioner (Darlene McDowell) updated as to any changes in my medical profile during the session(s) and understand that there shall be no liability whatsoever on the facial practitioner’s (Darlene McDowell) part should I fail to do so.

I also understand that the Gua Sha Practitioner (Darlene McDowell) reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which facial treatments are contraindicated.

I give my permission to receive the facial/facial treatment(s) purchased and agreed by the client which can include: The Gua Sha Facial, All Facials/Treatments, also can include Radio Frequency, Radio Frequency Skin Tightening, Cold Laser, High Frequency Treatments, Microdermabrasion, Hydra Facial, Dermaplaning, Oxygen Facial, No Needle Mesotherapy, Red Light (Photobiomodulation) Therapy and any/all facial or facial treatment agreed by the client and practitioner.

For Dermaplaning: You must read the Dermplaning Disclaimer/Consent Form and sign, as well as this form.

Click Here to > Dermaplaning Consent Form

The signer herewith will not hold The Gua Sha Facial Co., Darlene McDowell, responsible in any way, nor shall any claims be filed or valid for the facial/facial treatment(s) that I have agreed by signing the Disclaimer Consent Form for her to perform.

I have read and fully understand the disclaimer. I (the client) am 18 yrs of age or older.

By typing your name below, you authorize this as a legal binding agreement.

*E-Signature Please type your Full Name below. Today's Date.