PRE-TREATMENT HEALTH & ALLERGY DISCLOSURE

Sophie Carbonari

All facial and skin-care services

Please read carefully, then sign and date where indicated. This statement will be kept with your client record for legal and insurance purposes.

1. Personal Health Declaration

I, the undersigned client, declare that to the best of my knowledge:

• do not currently suffer from any infectious, inflammatory or otherwise active skin condition (e.g., dermatitis, eczema, psoriasis, cold sores, fungal infections) on the area to be treated unless disclosed below.

• do not have any known allergies, sensitivities or adverse reactions to cosmetics, skin-care ingredients, topical medications, latex or fragrances unless disclosed below.

• I am not under dermatological or medical care for a condition that could be aggravated by the planned treatment, or, if I am, I have obtained written clearance from my health-care provider.

If any of the above statements are untrue, partially untrue, or change in the future, I agree to inform the practitioner immediately in writing before any service is rendered.

2. Duty to Disclose & Ongoing Obligation

I understand that skin-care treatments may involve the use of active ingredients (e.g., AHAs, BHAs, retinoids, essential oils) that can provoke irritation or allergic responses.

I therefore accept a continuing duty to disclose, prior to each appointment, any:

• Recent cosmetic procedures (e.g., chemical peels, injectables, laser, microneedling).

• New medical diagnoses, medications, or changes in health status.

• History of fainting, seizures, or other conditions that may affect treatment safety.

Failure to provide complete and accurate information may increase the risk of adverse reactions and may void any right to claim damages.

3. Assumption of Risk & Limited Waiver

I acknowledge that:

• No treatment is entirely free of risk; minor redness, irritation or delayed hypersensitivity may occur.

• The practitioner will perform the service in accordance with professional standards and manufacturer instructions, relying on the accuracy of the information I provide.

Except in cases of proven negligence or breach of statutory duty, I waive any claim against the practitioner and the establishment for reactions or complications that arise from conditions, medications or allergies not disclosed on this form or in subsequent updates.

4. Data Protection

All personal and medical information collected on this form is processed in accordance with the EU General Data Protection Regulation (GDPR) and will be used solely to assess suitability for treatment, manage your client record, and comply with insurance obligations. Your data will not be shared with third parties without your explicit consent, except where required by law.

5. Declaration & Consent

I confirm that I have read and understood the above statements, that the information I have provided is complete and accurate, and that I consent to the proposed skin-care treatment under these terms.

Practitioner: Sophie Carbonari

Important: If at any time you are uncertain about a reaction or your suitability for treatment, consult a licensed medical professional before proceeding.

Notes