Back Facial

$70.00

Treat your back the same way that you would treat your face.Enjoy exfoliation, deep hydration and soothing massage to get rid of any impurities, acne, uneven skin tone and rough texture.
(approx 45 mins)

Please fill out and submit these online forms prior to your first visit:

Forms for Back Facial

Informed Consent for Facial and/or Peel Treatment

Informed Consent for Facial and/or Peel Treatment

  • You have the right to be informed about your skin rejuvenation treatment.

  • Date Format: MM slash DD slash YYYY
Health Questionnaire
Client Disclosure Form

Client Disclosure Form

  • Welcome to Endless Beauty SkinCare – Where Health and Beauty Become One

    My name is Kelly Tracy-Holly and I am the Owner/Advanced Aesthetician of Endless Beauty SkinCare. I was originally licensed in Arizona as an Aesthetician and Certified Medical Laser Technician. I moved back to Oregon with my family in 2009 and continue to be licensed in Arizona as well as Oregon. I have trained and worked beside a medical Internist, Family Practitioner MD and Specialty Vein MDs. I have been trained on Alex, YAG, CO2, Fractionated and Fraxel Lasers as well as IPL and BBL machines, a Microneedling Pen, the Skin Classic (High Frequency Device), and all levels of chemical peels. My knowledge in skin care has evolved over the 14+ years that I have been in business as I am always continuing to learn about the newest skin care ingredients and treatments that are available in the industry. I am also CPR/First Aid and Blood Borne Pathogen Certified.

    Services offered at Endless Beauty SkinCare include Waxing, Facials, Back Facials, Deramaplane Facials, Chemical Peels/Medical Grade Chemical Peels, Microneedling and High Frequency (treatment of broken capillaries, skin tags, cherry hemangiomas) with pricing starting at $20 and moving to $425 and above depending on packages and treatment combinations. All Payments are due at time of services.

    I have a collaborative agreement with Kimberly Canaday, ANP, Board Certified Adult Nurse Practitioner, and whom I can refer you to if you are interested in injectable services. I hold insurance policies with ASCP (Associated Skin Care Professionals) and APIS (Allied Professional Services, LLC).

    As a client I agree to follow any/all written and verbal pre and post care instructions that have or will be given to me regarding any/all of my treatments with Endless Beauty SkinCare and I understand that this consent shall remain in force from this time forward.

  • Date Format: MM slash DD slash YYYY
  • Additional Instructions:
    Please call 541.390.0066 with any questions or concerns.

HIPAA

HIPAA Consent

  • The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text can be obtained from Merz Medical Services, LLC. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov. We have adopted the following policies:
    1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
    2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
    3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
    4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
    5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
    6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
    7. We agree to provide patients with access to their records in accordance with state and federal laws.
    8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
    9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
  • I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
  • Date Format: MM slash DD slash YYYY

Be sure all four forms have been filled out and submitted prior to your first appointment.

Other Forms, if applicable

Parental Consent

Parental Consent

  • I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended as a result of the treatment.
  • Date Format: MM slash DD slash YYYY
Photo Release and Authorization

Photo Release and Authorization

  • hereby authorize Kelly Tracy-Holly, of Endless Beauty SkinCare, to reproduce and/or publish visual materials, including photographic images and video footage that may pertain to me. I understand that this material may be used in various publications, public affairs releases, newsletters, or for other related endeavors to promote/publicize Endless Beauty SkinCare. This material may also appear on my website, Facebook page or other social media outlets. This authorization is continuous and may only be withdrawn in writing by my specific rescission of this authorization.

    I hereby waive any right to inspect or approve the finished photographs or printed or electronic material that may be used in conjunction with them now or in the future, whether that use is known to me or unknown. I also waive any right to royalties or other compensation arising from or related to the use of the photographs or other materials.

    I hereby agree to release, defend, and hold harmless to Endless Beauty SkinCare and their agents, owners or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs and/or video footage.

    I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release.

  • Date Format: MM slash DD slash YYYY