Forms for Our Services

Brow and Lash Tinting
Dermaplane Consent

Dermaplane Information and Consent

  • Dermaplaning is a form of manual exfoliation similar in theory to microdermabrasion but without the use of suction or crystals. An aesthetician grade, sterile blade is stroked along the skin at an angle to gently “shave off” dead skin cells from the epidermis. Dermaplaning also temporarily removes the fine vellus hair of the face, leaving a very smooth surface.

    As with any type of exfoliation, the removal of dead skin cells allows home care products to be more effective, reduces the appearance of fine lines, evens skin tone and assists in reducing milia, closed and open comedones, and minor breakouts associated with congested pores.

    Dermaplaning can be an effective exfoliation method for clients that have couperose (tiny blood vessels near the surface of the skin), sensitive skin or allergies that prevent the use of microdermabrasion or chemical peels.

    Due to the contours of the face, certain areas of the face (such as the eyelids and nose) are not treatable using this method.

  • As your aesthetician, I will perform a thorough skin analysis prior to your first dermaplaning.

    If dermaplaning is not appropriate, you will be informed during this session and an alternative treatment may be recommended instead.

    If dermaplaning is not contraindicated, maximum results are obtained by participating in a series of treatments plus following a home care regimen.

    I will review your current daily regimen and skin care products, advise you on which products you should continue to use, and recommend any additional products or changes to your regimen to enhance your desired outcome.

  • I take every precaution to ensure that your skin is well hydrated and calm following each session. However, you may experience excessive dryness or even some peeling between sessions. Always contact me if you have any concerns.

    More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours. Dermaplaning may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this should occur, please contact me so that I can do a post-treatment follow up with you.

    After your treatment, SPF 30+ MUST be worn at all times. Tanning beds should never be used. You are making an investment in your skin: therefore, it is to your benefit to continue to protect it long after your series of treatments is completed.

  • Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for dermaplaning treatment and must be disclosed prior to treatment.
  • Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided. Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure or tanning beds). Although SPF 30+ should already be a part of your daily skin care, after dermaplaning, SPF 30+ must be applied daily to treated area for a minimum of two weeks. Twice daily cleanse the treated area with a gentle cleanser, followed by a moisturizer and finish with SPF 30+ sunscreen.

    If you have additional questions or concerns regarding your treatment or which products would be recommended for home care, you will consult your aesthetician immediately.

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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.

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Microneedling Information and Consent

  • Prior to receiving microneedling, I have been candid in revealing any condition that may have a bearing on this procedure, such as:

    • Pregnancy/nursing
    • Tendencies to cold sores/fever blisters
    • Botox (within 10 days)/ Fillers (within 30 days)
    • Active Acne/ Eczema/Psoriasis/Rosacea
    • Any type of infections/ Lupus/ Auto-immune diseases
    • Taking blood thinners or anticoagulants (discuss prior to Tx)
    • Recent facial peels or surgery
    • Use of Retin-A, Glycolic Acids, Accutane
    • Open sores/lesions/ broken or irritated skin
    • Raised surface (sebaceous hyperplasia/moles/keloids)
    • Skin Cancer/Any stage of melanoma
    • Allergy to Lidocaine/Stainless Steel
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Skin Classic

Skin Classic Information and Consent

  • The undersigned acknowledges that Kelly Tracy-Holly (Endless Beauty SkinCare ) has explained the nature of the Skin Classic procedure including the risks and dangers inherent like: infection, hyper or hypo pigmentation, redness, edema, or bruising. As in any cosmetic procedure, the treatment goal is for esthetic improvement, not perfection. The number of treatments necessary will vary between individuals and the areas being treated. Several factors including skin color, age, hormonal activity, inherited conditions, and other influences may decrease effectiveness of treatments.
  • The above points of information have been specifically discussed and made clear, and I have had the opportunity to ask any questions concerning this information.

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Waxing Client Information and Consent

  • Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

    I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

    I am willing to follow recommendations made by my aesthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the aesthetician immediately.

    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 the esthetician, whose signature appears below, 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.

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General Forms

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. A 24-hour cancellation notice is required. If appointments are continually cancelled last minute or re-booked there will be a $50 fee in order to re-schedule. Fee may be deducted from pre-purchased packages as well.

    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.

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  • Additional Instructions:
    Please call 541.390.0066 with any questions or concerns.

Health Questionnaire

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. 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.
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Makeup Questionnaire
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.
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Photo Release & 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.

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