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Lavender-Falls-Stone-Oak-Spa-San-Antonio


Lavender Falls Face & Body Spa LLC

 

PLEASE READ CAREFULLY & COMPLETELY

 

19239 Stone Oak Pkwy # 201

San Antonio, Texas 78258

Phone: 210-446-0903

www.sanantonio.lavenderskinspa.com

Online Booking Available

Client Information

 

First Name:  

Email Address:  

Street Address:  

Emergency Contact:  

Last Name:  

Cell Phone #:  

City:  

Contact #:  

 

Zip Code:  

 

 

Client Information: (Please check all that apply)

If you currently or previously have had any conditions or used any of the products listed below:

 

 

Accutane

Allergies
Botox/Dysport within the last week
Cortisone/Steroid Injections
Cosmetic Injections/Fillers in the last 2 weeks
Skin Lightening or Bleaching creams
Seizure Disorder
Skin Disease, Lesions
Eczema/psoriasis
High/Low Blood pressure
Lymphatic Disorder
Thyroid Condition
Recent Laser Treatments or Chem Peels
Facial Waxing within the last 24 hours
Retin-A within the 5 days of treatment
 

 

 

Rosacea

Skin Abrasions or Lesions
Cystic Acne
Sunburn
Metal bones, Pins or Plates
Any Active Infection
Phlebitis , Blood Clots, poor Circulation
Keloid Scarring
Blood Thinner Medication
Viral Infection/Influenza
Epilepsy
Heart Conditions

 

 

Information :

Are You currently under the care of a physician or Dermatologist?  

Explain:   

 

Any recent surgery, including plastic surgery?

Explain:   

 

Are you pregnant or is there a possibility of pregnancy? 

 

 

Do you have Allergies?  

List:   

 

Please list all medications you are taking: 

 

 

What are your skin concerns that you would like to improve or eliminate?   

 

Are there any specific requests you would like to make regarding your services today? 

  

Acknowledgements:

Liability Release, Waiver, Discharge and Covenant Not To Sue

This is a legally binding Release, Waiver, Discharge and Covenant Not to Sue (collectively, “Release”), made voluntarily by me, the undersigned Releasor, on my own behalf, and on behalf of my heirs, executors, administrators, legal representatives and assigns (hereinafter collectively, “Releasor,” I or “me”, which terms shall also include Releasor's parent or guardian, if Releasor is under 18 years of age ) to Lavender Falls Face and Body Spa LLC ("The Spa")

(A) As the undersigned Releasor, I fully recognize that there are dangers and risks to which I may be exposed during use of The Spa’s services, products or facility (the “Business” including but not limited to whirlpool bath tubs, vichy showers, facials, eyelash extensions, body wraps, chemical peels, body scrubs, eyelash tinting, microdermabrasion, microneedling, spray tanning, dermaplaning, waxing, massage, permanent cosmetics, eyebrow microblading, use of spa equipment, cosmetic or esthetic products or any activity at the facility located at 19239 Stone Oak Pkwy, Suite #201 San Antonio, TX 78258).

(B) As the undersigned Releasor, I understand that The Spa does not require me to participate in the Business, but I want to do so despite the possible dangers and risks and despite this Release.

(C) WITH INFORMED CONSENT, AND FOR VALUABLE CONSIDERATION RECEIVED, INCLUDING ASSISTANCE PROVIDED BY THE SPA, AS THE UNDERSIGNED RELEASOR, I AGREE TO ASSUME AND TAKE ON MYSELF ALL OF THE RISKS AND RESPONSIBILITIES IN ANY WAY ARISING FROM OR ASSOCIATED WITH THE SPA BUSINESS AND I RELEASE THE SPA AND ALL OF ITS AFILLIATES, OWNERS, MEMBERS, MANAGING MEMBERS, OFFICERS, DIRECTORS, PRINCIPALS, TRUSTEES, LEGAL REPRESENTATIVES, MANAGERS, EMPLOYEES, AGENTS, ADMINISTRATORS, ASSIGNS, AND CONTRACTORS (COLLECTIVELY “INDEMNITEES”), FROM ANY AND ALL CLAIMS, DEMANDS, SUITS, JUDGMENTS, DAMAGES, ACTIONS AND LIABILITIES OF EVERY NAME AND NATURE WHATSOEVER, WHENEVER OCCURRING, WHETHER KNOWN OR UNKNOWN, CONTINGENT OR FIXED, AT LAW OR IN EQUITY, THAT I MAY SUFFER AT ANY TIME ARISING FROM OR IN CONNECTION WITH THE SPA BUSINESS, ANY INJURY OR HARM TO ME, MY DEATH, OR DAMAGE TO MY PROPERTY (COLLECTIVELY “LIABILITIES”), AND I AGREE TO DEFEND, INDEMNIFY, AND SAVE INDEMNITEES HARMLESS FROM AND AGAINST ANY AND ALL LIABILITIES, INCLUDING LIABILITIES DUE TO INDEMNITEES OWN NEGLIGENCE, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY A PRE-EXISTING DEFECT, THE NEGLIGENCE (WHETHER SOLE, JOINT OR CONCURRENT), GROSS NEGLIGENCE, STRICT LIABILITY OR OTHER LEGAL FAULT OF THE THE SPA (OR ANY SUCH INDEMNITEE).

(D) AS THE UNDERSIGNED RELEASOR, I VOLUNTARILY ASSUME ALL RISK OF PERSONAL INJURY, SICKNESS OR DEATH SUSTAINED DURING UTILIZATION OF THE SPA’S BUSINESS. IN ADDITION I ASSUME ALL RISK  REGARDING SICKNESS, INJURY OR DEATH FROM COVID-19 SUSTAINED DURING UTILIZATION OF THE SPA’S BUSINESS.  I RECOGNIZE THAT THIS RELEASE MEANS I AM GIVING UP, AMONG OTHER THINGS, ALL RIGHTS TO SUE INDEMNITEES FOR INJURIES, DAMAGES OR LOSSES I MAY INCUR. I ALSO UNDERSTAND THAT THIS RELEASE BINDS MY HEIRS, EXECUTORS, ADMINISTRATORS, LEGAL REPRESENTATIVES AND ASSIGNS, AS WELL AS MYSELF. I AFFIRM THAT I AM OF SOUND MIND AND AM UNDER NO DURESS. I AGREE NOT TO UTILIZE THE THE SPA’S BUSINESS UNLESS I AM MEDICALLY ABLE AND I AGREE THAT THIS RELEASE SHALL BE GOVERNED FOR ALL PURPOSES BY TEXAS LAW, WITHOUT REGARD TO SUCH LAW ON CHOICE OF LAW.

I acknowledge Lavender Falls Face and Body Spa LLC has a no refund policy on any products or service. There will be no refunds for any reason. All services performed are without any guarantee.

I have read this entire Release.  I fully understand the entire Release and acknowledge that I have had the opportunity to review this Release with an Attorney of my choosing if I so desire, and agree to be legally bound by the release. 

By Opting-In to Promotional Emails, you are granting: Lavender Falls Face and Body Spa, 19239 Stone Oak Pkwy, San Antonio, TX, 78258, permission to email you. You may unsubscribe via the link found at the bottom of every email. (See our Email Privacy Policy (http://constantcontact.com/legal/privacy-statement) for details.) Emails are serviced by Constant Contact.

I agree that a $50 fee shall be charged to my credit card on file if I no-show and/or cancel or reschedule with less than 24 hours notice and/or arrive more than 30 minutes late to my appointment.  A 3% Transaction Fee shall be applied to all credit card payments to Lavender Falls Face and Body Spa LLC.

 

 

 

 

 

 

  The Information I Provided Is True & Correct

 

 

 

Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face and Body Spa LLC for your aesthetic needs.

Feel free to contact us at 210-446-0903 if you have any questions

     

 

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Signature Certificate
Document name: Intake
lock iconUnique Document ID: 3ad9a847a14c5079741bbc1ee2782bd215eaa4c3
Timestamp Audit
April 8, 2017 9:05 pm CSTIntake Uploaded by Lavender Falls Face and Body Spa LLC. - lavenderfallstx@gmail.com IP 162.198.97.65