Personal & Medical Information
Please fill out all the information in this form.
Name
*
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date / Fill this out if you'd like a birthday discount
Email
*
example@example.com
Phone Number
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Do you have any known allergies (orally or topically)? If so, please list them here.
Are you sensitive to fragrances?
If you have any medical conditions that I need to be aware of before your service(s), please list them here. If you are sensitive to flashing/moving lights, or have epilepsy please list that here as well.
Are you taking any antibiotics (oral or topical)?
Please list if you have any facial implants, piercings, dentures, or wear contacts
Do you have any medical devices or hardware I need to be aware of?
Photos: I consent for photographs and/or video images to be taken of me by Sea Breeze Beauty. I understand the images may be used for marketing purposes (website, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. Although photographs and/or video images will be used without identifying information such as name, I understand it is possible someone may recognize me. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever. I hereby release Sea Breeze Beauty and its employees, and any third parties involved in the creation of or publication of educational or marketing materials, from liability for any claims by me or any third party in connection with my participation. By signing this form, I confirm understanding of this consent. If I wish to withdraw my consent in the future, I may do so via written request submitted to Sea Breeze Beauty or by completion of a new form.
Please Select
Yes
No
Date
-
Month
-
Day
Year
Date
Please ONLY sign below if you agree to having photos / videos taken
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