Treatment Consent form

Skin Masters Rituals

Treatment Consent form
Today's Date:*

MonthDayYear
Date
Legal Name:

First NameLast Name
Sex:*
Birth Date

MonthDayYear
Age
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name *

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.
Service Requested*
Facial, Sauna Capsule, Massage, Body Treatment, Permanent Make-Up
List ALL ALLERGIES*
YesNo
If Yes where on your person?
YesNo
If YES please explain:
YesNo
If Yes, what type?
YesNo
If Yes where?
List any over the counter medications (including any vitamins, herbal supplements, aspirin, etc.) you take regularly.*
YesNo
If Yes please describe & explain
YesNo
If Yes, when? Which Drug?
YesNo
If yes, please describe
YesNo
If yes, please explain
YesNo

Have you had any of these health conditions in the past or present? Select all that apply.*

Rows	Yes	No
Cancer
Psychological Treatment
Hormone Imbalance
Systemic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Eczema
Epilepsy
Seizer Disorder
Fiver Blisters
Headache (chronic)
Hepatitis
Herpes
Immune Disorders
HIV/ AIDS
Lupus
Metal Bone Pins or Plates
Hysterectomy
Diabetes
Heart Problems
Varicose Veins
Arthritis
Asthma
Phlebitis
Blood Clots/ Poor Circulation
Insomnia
Keloid Scarring
Skin Disease/ Skin Lesions
Any Active Infection
NONE

Skin Masters Rituals