Health history intake form

YOU NEED ONLY FILL/SIGN THIS FORM ONCE.

It is important that you fully understand this information, so please read this document thoroughly.

The responses from this form are completely private and only seen by your treatment specialist.

The purpose of this health intake form is to provide your specialist with the most recent medical data to best inform them of any health conditions, current medications, allergies, and/or previous procedures that may not make you eligible for certain treatment offerings. This also helps the treatment specialist recommend specific treatments based on your desired goals.

I understand that I have read and completed the questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.

I am aware that it is my responsibility to inform the Specialist of my current medical or health conditions and to update this history. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically. I understand that the services offered are not substitutes for medical care and any information provided by the Specialist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the specialist in giving better service and is completely confidential. The treatments I receive here are voluntary and I release, Sonia Felix, from any liability and assume full responsibility thereof. 

I have read and fully understand this agreement and all information detailed above and I consent to the terms of this agreement. I do not hold Specialist, sonia Felix, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I also release, Sonia Felix, and the Beautyholic, from any liability that may arise from this procedure.

I also state that I read and write in English.

If you have any questions regarding the procedure, ask your service provider professional prior to signing the consent form or email us: inquiries@thebeautyholicbar.com