Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

MM

DD

YYYY

Have you received any Botox or dermal fillers in the past two weeks? *

Yes

No

Have you had a fever or cold sores in the last 7 days? *

Yes

No

The studio is located upstairs in a loft space, are you comfortable going up a single flight of stairs?

Yes

No

Acknowledgement *

I do fully understand all the questions above and have answered them all correctly and honestly. I understand that my skincare professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition and lifestyle. I agree to actively participate in following appointment schedules and home-care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skincare professional immediately. I release and hold harmless the skincare professional Michele Glanden, Craving Quiet, harmless from any liability for adverse reactions that may result from these treatments. Services such as basic facials, high frequency, Kansa wand, and sauna bag, are performed without medical supervision.

Agree