Skin + Body Bar Consultation and Consent Form

Skin + Body Bar Consultation and Consent Form
Name*

First Name Last Name
Date of Birth

MonthDay Year
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you currently being treated by a physician for any illness, virus, infection or condition?*

YesNo
If yes, please describe.*
In the past 12 months, have you used accutane/isotretinoin?*

YesNo
Do you have diabetes or any auto-immune disease?*

YesNo
If yes, please describe.*
What over the counter and/or prescription skin care products are you currently using?*
Please list any medications you are taking including over-the-counter, herbs, herbal, vitamins and supplements: *
Do you have any skin conditions?*

YesNo
If yes, please describe.*
What are your skincare goals?*

Control acne breakoutsFirm SkinRevise hyperpigmentationI just want to relax.
Do you have any allergies or sensitivities?*

YesNo
If yes, please describe.*
Are you pregnant?*

YesNo
Minors (all clients under the age of 18- unless otherwise emancipated) can only receive treatments with written parental/legal guardian consent.

In collaboration with the consenting adult and child, the esthetician will assist in establishing goals for the session(s).

For clients age 15 and under, the parent/guardian must always be present in the treatment room.
I, First and Last Name, am the legal parent/legal guardian of Minor's First and Last Name . I have read the above information and give permission for my child, age Age , to be serviced at Rawe Beauti Skin + Body Bar.
Today's Date*

MonthDay Year
Date
Signature*

Clear
By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.
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