Treatment Consent Form

CLIENT INFO:

Name

Date of Birth

Phone Number

Email Address

Address

Gender

Male Female

SERVICES PERFORMED:

Therapist Name

Facial / Massage / Waxing / Lashes / Body Wrap / Body Scrub / Chemical Peel / Other:

Please read and answer all questions to the best of your knowledge and ability. It is important for your safety and treatment of your skin to answer honestly. Tick for yes and leave open for no.

Please List any allergies

Have you EVER had or are prone to any of the following? (please select all that apply)

Cold sores Hives Keloids Rash

If so how often:

Is it active now?

Last breakout:

Do you suffer from chronic pain?

Yes No

If yes, please explain:

What makes it better?

What makes it worse?

Have you had any orthopedic injuries?

Yes No

If yes, please explain:

Do you exfoliate?

Yes No

If yes, how often?

List all medications currently taking, including vitamins and birth control:

Are you currently taking Antibiotics?

Yes No

Have you had any problems with your heart or lungs?

Yes No

Have you had any surgeries in the last 12 months, including cosmetic?

Yes No

If yes, what kind and when:

Have you ever had a reaction to any skin care products?

Yes no

If yes, to what and when?

Have you had any of the following services in the last week?

Microdermabrasion Chemical Peel Collagen Waxing

If yes, when?

What improvements would you like to see in your skin?

What products do you currently use?

Do you wear sunscreen?

Yes No

CONSENT AGREEMENT

I affirm that I have stated, to the best of my knowledge and ability that all of my known medical conditions have been disclosed and answered on this form correctly and honestly. I agree to hold harmless and without liability or lawful action toward Ngawela Lifestyle Spa and all of their affiliates. I understand to keep the Spa updated as to any changes in my personal profile including medical, medications, treatments and lifestyle changes and fully understand that there shall be no liability held in any case or damages. By signing below I fully understand all complications and risks associated with all services rendered and treatments provided and will not hold Ngawela Lifestyle Spa/affiliates responsible for all damages. I agree that I will cover all costs for the service or treatment received.

Printed Name

Date

Email: info@ngawelalifestylespa.com | Contact: +268 7637 5112 / +268 2416 3122

Treatment Consent Form

CLIENT INFO:

SERVICES PERFORMED:

Self care is not a luxury. It’s a necessity.