FORM – Medical History & Consent

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Medical & Health Related Questions

I understand and have read and completed this 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 esthetician/skin care therapist of my current medical or health conditions and to update this history. I certify that I have read, and fully understood the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered for me to make an informed decision with proceeding with treatments. The treatments I receive here are voluntary and I release La Clinica and the skin care professional from liability and assume full responsibility and liabilities associated with this procedure. This consent is valid for all of my treatments and in the future as well. I agree to the treatment and future treatment and I am fully aware of its associated risks.

I understand and have read and completed this questionnaire truthfully and I have been informed and I am aware of its associated risks. I agree to the treatment and future treatments.