Consent Form

Client Name

First NameLast Name

Date of birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Esthetician's Name

First NameLast Name

Please take a moment to answer the following questions

Are you presently taking any medications?

Please list

Are you pregnant?

Do you have any allergies to cosmetics, food or drug?

Please specify

What skin care products do you currently use?

Please specify

Do you use acne medication?

Have you had skin cancer?

Please check if you are affected by or have any of the following

Are you taking oral contraceptives?

By signing below, I agree:

If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.

I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future.

I agree to follow aftercare instructions given to me by the technician. Failure to do so can result in damage. Mayra's Beauty Room LLC will not be held liable to any improper aftercare or irritation.

Client Signature

Date