WorkShop Registration and consent Name * First Name Last Name Email * Phone * (###) ### #### Will you be receiving botox or any other cosmetic fillers within 3 months of workshop date? * Facial Gua Sha is not advised within 3 months of any cosmetic fillers however in most cases you can work around the injected area 4 weeks post injection. Yes No Still Unsure Please select any skin conditions you are currently experiencing * Acne Ocasional/Hormonal Breakouts Rosacea Rashes or Irritation Sunburn Fever in the last 24 hours Sinus pressure or drainage Please list any allergies * I acknowledge the risk associated with any skin treatment and will hold Veracity Skin Studio, Memphis Wellness Collective and its staff harmless from any liability that may result from this self-care treatment. I have given an accurate account of the questions asked above including all known allergies. I understand that every precaution will be taken to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold Veracity Skin Studio or Memphis Wellness Collective responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today in this workshop. Furthermore, I attest that I will not use the information shared in this workshop in a professional environment or on social media. I acknowledge that this workshop is intended for self-care only and does not constitute professional training. Please select Yes below if you agree to the above statement. Selecting YES below releases Veracity Skin Studio, Memphis Wellness Collective, and its staff from all liability Yes No Please select the workshop option below * This workshop will be instructed with the CJB Pocket Jade tool (Retail $28). You may bring your own tool or purchase the CJB Pocket Jade tool now for $20 to use at the workshop. Tools will be available for purchase at full price the day of the workshop. $75 I'd like to purchase a Gua Sha Tool $55 I will bring my own Gua Sha tool Thank you!
