Smart PDF Form

**Client Information**
Name:
Date of Birth:

MonthDayYear
Date
Address:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
**Services**
This consent form applies to the following services:
- Basic Facials
- Microdermabrasion
- Dermaplaning
- High Frequency
- Electrolysis
- Chemical Peel
**Health Information**
1. Do you have any allergies or sensitivities? If yes, please list:
2. Are you currently taking any medications, including topical treatments? If yes, please list:
3. Do you have any skin conditions or medical issues I should be aware of? If yes please explan
4. Are you pregnant, nursing or undergoing hormone treatments? YES/NO
**Consent to Treatment**

I understand that…
1.. The services provided are for cosmetic purposes only and not intended to diagnose, treat, or cure any medical conditions.

2.. I have disclosed all relevant medical history and current conditions to the best of my knowledge.

3.. While every effort will be made to ensure my comfort and safety, results are not guaranteed and may vary.
**Risks and Acknowledgments**

I acknowledge that:
1.. Potential risks of treatments include, but are not limited to redness, irritation, swelling, hyperpigmentation, infection, and scarring.

2.. I am responsible for the following all pre-treatment and post- treatment care instructions provided by the practitioner.

3.. I will inform the practitioner immediately if I experience any adverse reactions during or after the procedure.
*Waiver and Hold Harmless Agreement*
I agree to release, waive, and hold harmless {GlowybyKari} and its employees, contractors, and affiliates from any liability, claims, or damages arising from the services provided. I understand and accept that there are inherent risks involved in the aesthetics treatments and assume full responsibility and for any consequences.
**Photography Release (Optional)**
I consent to the use of my photographs for the documentation, marketing, and educational purposes. My identity will remain confidential unless I provide explicit permission otherwise.
Initials:
*Acknowledgement and Signature*
By signing below, I confirm that I have read and understand this consent form, that I have been informed of the nature and purpose of the treatments, and that all my questions have been answered satisfactorily. I voluntarily consent to receive the indicated services.
Signature:
Date:
Practitioner’s Signature:
Date:
Should be Empty:

**Client Information**

**Services**

**Health Information**

**Consent to Treatment**

**Risks and Acknowledgments**

*Waiver and Hold Harmless Agreement*

**Photography Release (Optional)**

*Acknowledgement and Signature*

Client Information

Services

Health Information

Consent to Treatment

Risks and Acknowledgments

Waiver and Hold Harmless Agreement

Photography Release (Optional)

Acknowledgement and Signature