#103 7228 192 St Surrey BC
778-889-0620
Advanced Facial / Skin Treatment Consent Form
Client Name
(Required)
Full Name
Phone
(Required)
Email
(Required)
DOB (18+ only)
(Required)
MM slash DD slash YYYY
Facial Services Included (ALL)
(Required)
Laser Club Classic Facial
Hydra Facial
Microneedling
Dermaplaning
Chemical Peel
Acne Facial
Anti-Aging Facial
Sensitive-Skin Facial
LED Therapy
OxyGeneo Facial
MEDICAL HISTORY (YES / NO)
Are you pregnant?
(Required)
Yes
No
Breastfeeding?
(Required)
Yes
No
Currently on Retinol/Accutane?
(Required)
Yes
No
History of keloids?
(Required)
Yes
No
Rosacea?
(Required)
Yes
No
Severe acne?
(Required)
Yes
No
Any allergies (skincare, latex, lidocaine)?
(Required)
Yes
No
Do you have cold sores/herpes?
(Required)
Yes
No
Autoimmune disorders?
(Required)
Yes
No
Diabetes?
(Required)
Yes
No
Active eczema / psoriasis / dermatitis?
(Required)
Yes
No
Chemical peel / laser treatment in last 4 weeks?
(Required)
Yes
No
Have you had Botox or fillers recently?
(Required)
Yes
No
If yes, When?
SKIN ANALYSIS QUESTIONS
Skin Type
(Required)
Normal
Oily
Dry
Combination
Sensitive
Do you experience hyperpigmentation?
(Required)
Yes
No
Do you have enlarged pores?
(Required)
Yes
No
Do you tan easily?
(Required)
Yes
No
Do you use AHA/BHA acids at home?
(Required)
Yes
No
Do you pick your skin?
(Required)
Yes
No
CONSENT & IMPORTANT NOTES
Some facials may cause temporary redness, sensitivity, dryness, or peeling.
Results vary depending on skin condition and aftercare.
Microneedling may cause pinpoint bleeding and temporary inflammation.
Chemical peels may require downtime and strict sun protection.
SPF use and avoiding sun exposure after treatment is required.
CONSENT & LIABILITY WAIVER
CONSENT & LIABILITY WAIVER By submitting this form, I agree to the following terms regarding my treatment at RK Beauty Club. 1. Informed Consent, Capacity & Voluntary Decision I confirm that I am 18 years of age or older (or have a legal guardian present) and have the legal capacity to consent. I have read and understood the details of the treatment I am requesting. I have had the opportunity to ask questions regarding the procedure, risks, benefits, alternatives, and expected outcomes, and all questions have been answered to my satisfaction. I confirm that I am choosing this treatment voluntarily, without coercion, and I understand I may withdraw my consent at any time before or during the procedure. 2. Medical Accuracy & Responsibility I certify that the medical history and health information I have provided is truthful, accurate, and complete. I understand that undisclosed conditions, allergies, or medications (e.g., blood thinners, Accutane) may affect my safety and the treatment outcome. I assume full responsibility for any adverse reactions resulting from my failure to disclose such information. 3. Risk Acknowledgement & No Guarantees I understand that all aesthetic procedures carry inherent risks, including but not limited to: pain, redness, swelling, blistering, scarring, discoloration, sensitivity, infection, allergic reactions, and healing variations. I acknowledge that results are not guaranteed, may vary by individual, and that "touch-ups" or additional sessions may be required at my own expense. 4. Aftercare Commitment I agree to strictly follow all pre- and post-treatment instructions provided by RK Beauty Club. I understand that failure to follow these instructions may increase the risk of complications, infection, or altered results, for which the clinic cannot be held responsible. 5. Financial Policy & Refunds I understand and agree to the clinic’s financial policy. I acknowledge that all payments and deposits are non-refundable (except where required by law). I also agree to provide at least 48 hours' notice for cancellations to avoid forfeiture of deposits or cancellation fees. 6. Release of Liability I hereby release, waive, and discharge RK Beauty Club, its owners, technicians, and staff from any liability, claims, or demands related to treatment outcomes, complications, or reactions that result from my consented procedure, except in cases of proven gross negligence. 7. Data Privacy & Media Release Privacy: I understand that my personal and medical information will be collected, stored, and used in accordance with applicable privacy laws (e.g., PIPA/PIPEDA). Media: Unless I have explicitly indicated otherwise in writing, I grant permission for before/after photos and videos of my treatment to be used for training, educational, and marketing purposes.
Consent
(Required)
I have read, understood, and agree to the Consent & Liability Waiver terms.
Signature
(Required)
Type in Your Full Name
