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Private 1:1 Session — Intake & Consent

Please complete this form before your private 120-minute Zoom session with Yulia. It takes about 5 minutes. Your answers and photos help Yulia prepare a plan for your face and posture, and are kept confidential.

About 5 minutes. Have two photos ready: one facing the camera (face and neck) and one side profile.

Start

Disclaimer

Disclaimer for Online Private 1:1 Session with Yulia Diumea. Please read this disclaimer carefully before booking any online facial massage or face yoga services. By booking and participating in these services, you agree to the terms and conditions outlined below.

 

Not Medical Advice: The services provided are for relaxation and aesthetic purposes only. They are not a substitute for professional medical advice, diagnosis, or treatment. If you have any medical conditions or concerns, please consult with a healthcare professional before participating.

 

Results May Vary: Individual results may vary. The effectiveness of facial massages and face yoga depends on various factors, including skin type, consistency of practice, and individual health conditions.

 

Personal Responsibility: You are responsible for any actions taken based on the information provided during the sessions. Ensure you understand the techniques and exercises before practicing them at home.

 

One-Time Rescheduling: Clients are allowed to reschedule their appointment one time within the same month. To reschedule, please contact us at least 24 hours before your scheduled session.

 

Forfeiture of Payment and Time Slot: If you fail to reschedule within the allowed period or miss your rescheduled session, you will forfeit both your payment and the time slot. No refunds or additional rescheduling will be provided.

 

How to Reschedule: To reschedule your session, please email us at yuliadiumea@gmail.com. Include your original appointment details and preferred new time.

 

No Liability for Injuries: We are not liable for any injuries or adverse effects resulting from the use of our services. Follow all instructions carefully and discontinue use if you experience any discomfort.

 

Service Interruptions: We are not responsible for technical issues or interruptions in service that may affect your session. In the event of such interruptions, please contact us to discuss rescheduling options.

 

Data Protection: Your personal information will be kept confidential and used solely for the purpose of providing the services. We will not share your information with third parties without your consent.

 

Session Recording: Sessions may be recorded for quality and training purposes. By participating, you consent to being recorded.

 

Contact: yuliadiumea@gmail.com · +1 951 855 0546 · 41920 6th Street, Suite F, Temecula, CA 92590.

 

By booking a session, you acknowledge that you have read, understood, and agree to all terms and conditions outlined in this disclaimer.

Question 2 of 20

Do you agree with the disclaimer above?

A

Yes, I agree

B

No

Question 3 of 20

Your age

Question 4 of 20

Which areas of your face and neck would you most like to improve?

Question 5 of 20

Do any of these medical conditions apply to you? Check all that apply.

(Select all that apply)
A

Pregnancy

B

Epilepsy

C

Cardiac or vascular disease/condition

D

Acute inflammation

E

Unhealed wounds

F

Fragility of blood vessels

G

Eczema

H

Psoriasis

I

Neoplasms (abnormal nevi)

J

Abnormally high or low blood pressure

K

Herpes virus

L

Neuritis of the facial nerve

M

Alopecia

N

Enlarged thyroid glands

O

Oral diseases

P

Claustrophobia

Q

Depression

R

Rosacea

S

Skin cancer or pre-cancer

T

Communicable diseases

U

Melanoma

V

Thrombosis or thrombophlebitis

W

Infectious diseases or tuberculosis

X

Diabetes

Y

None of these

Question 6 of 20

In the last 6 months, have you had any of the following? Check all that apply.

(Select all that apply)
A

Traumatic brain injury

B

Surgery

C

Ear, nose or throat disease

D

Eye surgery

E

Other

F

None of these

Question 7 of 20

Please list any medications you take.

Question 8 of 20

Are you allergic to any foods or medications? Please list them.

Question 9 of 20

How would you describe your skin type?

(Select all that apply)
A

Normal

B

Oily

C

Combination

D

Dry

Question 10 of 20

Have you had any of these treatments or procedures? Check all that apply.

(Select all that apply)
A

Recent injection (biorevitalization)

B

Neurotoxin (Botox, Dysport)

C

Hyaluronic acid fillers (e.g., Juvederm)

D

Thread lifting

E

Long-term implants

F

Blepharoplasty (eyelid surgery)

G

Rhytidectomy (face-lift)

H

None of these

Question 11 of 20

What is the date of your last injection? Write "none" if not applicable.

Conditions prior to your online consultation

RESTRICTIONS: I understand that if I have had derma filler within the past 6 months or neurotoxin (Botox, Dysport, Juvederm) within the past 1 month, it is possible that the massage can break down and diminish the effectiveness of the derma filler or neurotoxin. I also understand that following my massage sessions, it is best to avoid derma filler for 6 months and neurotoxin for 1 month.

BENEFITS: Tightens and lifts aging skin. Over time, new collagen is produced to further tighten the skin, by increasing blood and lymph flow, resulting in healthier, smoother skin and a more youthful appearance.

Question 13 of 20

I agree the nature and purpose of this massage, with possible complications, have been fully explained to my satisfaction. No guarantee has been given by anyone as to the results that may be obtained by this massage.

A

Yes, I agree

B

No

Question 14 of 20

I have read this consent and certify that I understand its contents in full. I have had enough time to consider the information and feel that I am sufficiently advised to consent to this massage.

A

Yes, I consent

B

No

Question 15 of 20

Upload photo 1: facing the camera, showing your face and neck. Photos are for progress tracking only and will not be shared with anyone.

file_upload
insert_drive_file

Question 16 of 20

Upload photo 2: side profile.

file_upload
insert_drive_file

Question 17 of 20

Your phone number

Question 18 of 20

Best way to contact you?

A

Email

B

Phone

Question 19 of 20

Best time of day to reach you?

A

Morning

B

Noon

C

Afternoon

D

Evening

E

Night

Question 20 of 20

Signature: type your full legal name and today's date (MM/DD/YYYY). This confirms your agreement to the disclaimer and consent above.

Confirm and Submit