Lash Lift & Brow Lamination

Lash Lift & Brow Lamination
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES
I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.
DATE

MonthDayYear
Date
SIGNATURE
IF PERSONAL REPRESENTATIVE
NAME
The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising
DATE

MonthDayYear
Date
SIGNATURE
I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
RELATIONSHIP TO PATIENT
IF PATIENT IS A MINOR
PARENT / LEGAL GUARDIAN
DATE

MonthDayYear
Date
Iunderstand that the practice cannot condition treatment on whether or not I sign this authorization.
SIGNATURE
IF DESIRED, COPY PROVIDED:
(initialed by team member, copy provided by )
This form is provided by My Social Practice for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like youneed legal consultation in addition to what we've provided, be sure to consult your practice attorney including seeking advice pertaining toand Human Services regulations. My Social Practice is a social mediamarketing company. We are NOT attorneys, and although this form isbased on our own research to ensure compliance, it does not represent
HIPAA compliance, the HITECH Act, and the U.S. Department of Health

You may download this form as a PDF, at no charge, for printing yourself at: MySocialPractice.com/hipaaform
INDEMNITY FORM / CLIENT CONFIDENTIALITY FORM
Client Name
Address
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Previous discomfort, stinging and adverse reactions please check the box(s)
Any medications
Other relevant information
Precare instructions: No use of any lash growing system or oils on eyelashes night before or day of service. Discontinue use of any active skincare ingredients such as retinols, tretinoin, salicylic, or glycolic acid around eyes/eyebrows 5-7 days before service. Aftercare instructions: Do not get eyelashes wet, no steam, sweat, oils, or makeup on eyebrows or eyelashes for minimum of 24 hrs. Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?
Did you experience any reaction to these treatments?
Please provide details of this reaction
Did you seek medical advise from a doctor or specialist as a result of this reaction?
Please note: NO / YES & what was the advise of your doctor/treatment given
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s. I also agree that I have followed any precare instructions as well as fully understand the aftercare instructions.
SIGNATURE
DATE

MonthDayYear
Date
TREATMENT BEING PERFORMED
Should be Empty:

Lash Lift & Brow Lamination

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES

IF PERSONAL REPRESENTATIVE

IF PATIENT IS A MINOR

IF DESIRED, COPY PROVIDED:

INDEMNITY FORM / CLIENT CONFIDENTIALITY FORM