Butt_Cupping_Consent

Butt Cupping Intake Form
General Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
Email*
example@example.com
Occupation
Emergency Contact Name
Phone#
How did you hear about us?

Service Information
What concerns would you like addressed today?
Do you want to lose body fat?*

YesNo
If yes, from what area:
Do you want to tighten skin on your body?*

YesNo
If yes, from what area:
Do you want to reduce cellulite?*

YesNo
If yes, from what area:
Please list your regular exercise habits:
Please describe your current dietary habits:
How many ounces of water do you drink daily?

Consents
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

By signing below, I agree to the following:
I have completed t his form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any cond ition(s) that would make the requested treatment unsuitable. I will inform the technician of any d iscomfort I may experience at any time during my treatment to allow them to adjust
accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries. losses, side effects, or damages which might occur to me while I am undergoing this procedure. 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.
Take Photo*
Name Printed*
Signature*

Clear
Geolocation
Should be Empty:

Butt Cupping Intake Form

Medical History

Service Information

Butt Cupping Consent Form

Consents