U&I Spa Inc

130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION

2. MEDICAL INFORMATION

3. HEALTH HABITS

*Do you...
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4. SKIN CARE HISTORY

5. CLIENT SIGNATURE

I understand, 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/body from treatments received.

I have discussed all I need to know with my aesthetician. My aesthetician has thoroughly informed me about the procedure, any risks and aftercare.

The treatments I receive here are voluntary and I release this institution, U&I Spa and/or skin care professional from liability and assume full responsibility thereof.