Embrace Informed Consent
Use the original attachment as reference and preserve the original wording and order of all extracted fields.
Client Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
City
*
State
*
ZIP
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Treatment/Procedure
*
Consent Initials
Initial - I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure
*
Initial - I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved
*
Initial - Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications
*
Initial - I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form
*
Initial - I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost
*
Initial - I have read and understand all pre-treatment, post-treatment, and home care instructions
*
Initial - I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes
*
Signatures
Client Name (Printed)
*
Client Signature
*
Client Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Technician/Esthetician Name
*
Technician/Esthetician Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: