• Today's Date*
     - -

  • Your Breast Friend

    It's time to nurture you
  • Birthday
     - -
  • Format: 0000-000-000.
  • How did you hear about Your Breast Friend?*

  • Medical History

  • Are you currently under the care of a physician or skin care therapist?
  • Any recent surgery? (including plastic surgery)
  • Tick those that are applicable to you:
  • Do you suffer from sinus problems?
  • Do you ever experience claustrophobia? If yes, please let me know in more detail

  • Female Clients:

  • Are you pregnant or breastfeeding?
  • Are you comfortable with having a breast treatment?
  • If yes, do you consent to having the breast treatment?

  • Your Skin

  • Have you had a facial treatment before?
  • Have you had a breast treatment before?
  • What do you consider your skin type?*
  • Tick any that you currently using:
  • Tick if you have had any of these treatments
  • If yes to the above, roughly when was it?
  • Select all products you currently use on your skin?*
  • Do you use sunscreen?*

  • Customise your Treatment:

  • Your Breast Friend Client Consent & Acknowledgment Form

  • By submitting and signing this form, I confirm that I understand and agree to the following:

    - I give permission to receive facials, skin treatments and/or breast treatments
    - I understand that my esthetician is not a medical professional and does not diagnose conditions, treat illnesses, or prescribe medication.
    - I confirm that I have received medical clearance to undergo these treatments, if necessary.
    - I understand that while all products are chosen with care, individual reactions may occur due to allergies or skin sensitivities.
    - I may experience temporary redness, tightness, swelling, or irritation, which typically resolves within 72 hours.
    - I accept the risk of allergic reactions if I am sensitive to any product ingredients.
    - I understand that not using sunscreen may increase the risk of sunburn, skin damage, or hyperpigmentation, and I should avoid excessive sun exposure directly after treatment
    - I acknowledge that this is an elective, non-medical cosmetic treatment and no medical claims are being made.
    - I agree to inform my esthetician of all relevant medical conditions, medications, and any changes to my health.
    - I understand that my physical condition may involve additional risks and that I should communicate any discomfort during the session.
    - Either I or the esthetician may end the session at any time.
    - I have had the opportunity to ask questions and all my concerns have been addressed.
    - I confirm that the information I have provided is accurate and complete.
    - I give consent for all future treatments.

    Use of Handmade Skincare Products
    As part of this treatment, Your Breast Friend may use handmade, small-batch products made with natural and cosmetic-grade ingredients.
    These products are:
    - Prepared in a clean, hygienic environment
    - Not for retail or commercial sale
    - Used only during treatment
    - Free from known harsh chemicals and preservatives

    I understand these products are not commercially tested. I have disclosed all known allergies and sensitivities and accept responsibility for any reactions that may occur. I understand this treatment is not a substitute for medical care and release Your Breast Friend from liability for any reaction or injury resulting from the treatment.

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