Adara Beauty & Wellness Medspa
Model Registration Questionnaire
Client Information
1. Full Name:
First Name
Last Name
2. Date of Birth:
-
Month
-
Day
Year
Date
3. Phone Number:
4. Email Address:
example@example.com
5. Emergency Contact Name & Number:
6. Preferred method of contact (text, phone, email):
Treatment Interest
7. Which service(s) are you interested in modeling for? (Circle or mark all that apply)
Botox/Xeomin
Lip Filler
Hyperhidrosis Treatment
Chemical Peel
Microneedling
Hydrodermabrasion
Other
8. Have you had this treatment before? If yes, when and where?
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Adara Beauty & Wellness Medspa
Model Registration Questionnaire
9. Are you open to having your photos/videos used for training or promotional purposes?
Medical History
10. Are you currently under the care of a physician for any medical condition?
11. Do you have any of the following conditions (check all that apply):
Autoimmune Disease
Neurological Disorders
Bleeding Disorders
Active Skin Infections (acne, eczema, etc.)
Cold Sores
History of keloids or poor wound healing
12. Are you pregnant, breastfeeding, or trying to conceive?
13. Do you have any allergies, especially to lidocaine, numbing agents, or medications?
14. Are you currently taking any medications, supplements, or blood thinners?
Consent and Expectations
15. Do you understand this is a model appointment and services may be performed for training or promotional content?
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Adara Beauty & Wellness Medspa
Model Registration Questionnaire
Yes
Yes
Yes
I confirm that the information provided is true to the best of my knowledge.
I understand and consent to receive the treatment(s) as a model.
Signature:
Date:
-
Month
-
Day
Year
Date
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Adara Beauty & Wellness Medspa
Model Registration Questionnaire
Photo Submission Form for Model Applicants
To help us evaluate your suitability for model services, please submit clear, makeup-free photos with the following views:
Full face - front-facing
Left profile
Right profile
Close-up of area to be treated (forehead, lips, underarms, etc.)
Optional: Before/after photos of past treatments (if applicable)
Instructions for Submission:
- Email photos to: info@adarabw.com with subject line 'Model Application Photos - [Your Name]'
- Or upload via our secure form at: [Insert submission link or QR code here]
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