Pregnancy Client Consent Form

Pregnancy Client Consent Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many weeks pregnant are you?
Is this pregnancy considered:
Has your doctor or midwife advised you to avoid any beauty treatments?
If yes, please provide details
Have you experienced any of the following during this pregnancy?

Other
If other, please specify below:
Have you noticed your skin become more sensitive during pregnancy?
Have you had any previous reactions to beauty treatments in a salon?
If yes, please specify below
Please list any medications prescribed for your pregnancy
Do you have any known allergies or medical conditions that may affect your appointment? If yes, please list below
Acknowledgment
I understand pregnancy can make my skin & eyes more sensitive and may increase the likelihood of irritation or allergic reaction
I understand that hormonal changes during pregnancy may affect how my skin, hair and lashes may respond to treatments and that results cannot be guaranteed
I understand that patch testing may be required if my beauty therapist advises so
I understand I should advise my technician immediately if I feel unwell, dizzy or uncomfortable during my appointment
I understand that I may request a break or stop my treatment at any time
I confirm that I HAVE NOT been advised by my doctor or midwife to avoid my beauty appointment
I confirm that the information I have provided is true and complete. I understand that with holding medical or pregnancy information may increase the risk of adverse reactions. I release Brows By Mak from liability for complications arising from undisclosed information or from normal risks associated with beauty treatments during pregnancy. I understand that Brows By Mak will keep this information confidential and for treatment use only. I understand that Brows By Mak reserves the right to decline or discontinue the service if it is considered unsafe.
Signature
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Pregnancy Client Consent Form

Acknowledgment