Client Consent
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of employment:
blanks
*
Type of employent:
blank
*
.
I am here today to do the following treatments:
*
facial
lash extensions
lash lift
lash lift with tint
microdermabrasion
microneedling
peel
permanent makeup
tinting
waxing
List any allergies (if none, please write "none"):
*
List any health issues you may have had or currently having (if none, please write "none"):
*
I have had Botox and or filler in the last 10 days?
*
Yes
No
I am have used Retin A in the last 2 weeks?
*
Yes
No
Yes and I still want procedure/procedures
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved by Weekend B Skincare.
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. 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 Esthetician immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and full understand this agreement and all information detailed above.
I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Weekend B Skincare responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.
I have read and agree to all terms:
*
Parent Name (if client is a minor)
First Name
Last Name
Signature of Parent if Client is a Minor
Submit
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