INFORMED CLIENT CONSENT FORM 2021

INFORMED CLIENT CONSENT FORM
NAME
DATE of BIRTH

MonthDayYear
Date
Address

ADDRESS

Street Address Line 2

CITYState / Province

ZIP
ZIP
PHONE
EMAIL
example@example.com
This concent waiver will remain in full force and effect for a period of one year from the date and name entered. This concent waiver will then need to be completed on an annual basis. Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial

I hereby consent to and authorize the technician/esthetician to perform the followingFacialWaxingLash LiftBacial (Back Facial)ConsultationOther Not Listed
Said treatment/procedure with Amy Smith, Esthetician, has been explained to me, along with the risks and hazards involved. Along with possible benefits, risks, and complications.
All information and/or contraindications have been requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.

I voluntarily agree to undergo this treatment/procedure after the nature and purpose of thisAlthough it is impossible to list every potential risk and complication, I have been informed ofI understand that it is imperative to my health and safety that I disclose all of the informationI understand that no specific guarantees of the results can or have been made and that there is theI have read and understand all pre-treatment, post-treatment, and home care instructions. I
Consent for Treatment
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be
an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from
receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any
claims related thereto. I give my consent to receive treatment from this practitioner.
There is a possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.

I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
For advertising, and promotional purposes.

I consent to “before-and-after” photographs for the purpose of documentation, potential
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution 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 been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.
Client Name (Printed)
Your typed name will serve as your signature in agreeance of above.
Date

MonthDayYear
Date
Should be Empty: