Minor Consent & Authorization

Name

First NameLast Name

Date of Birth

Date

Name

First NameLast Name

Relationship to Minor:

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select all that apply:

Does the minor have any allergies?

if yes, please list all allergies (medications, latex, adhesives, skincare ingredients, dyes, etc):

Is the minor currently taking any medications or receiving any medical treatments that may affect or contraindicate the requested service?

if yes, please specify:

Skin & Medical Conditions: (please select all that apply)

If other, please specify:

Is the minor currently using any of the following? (please select all that apply)

If other, please specify:

Has the minor received any of the following within the past 2 weeks? (select all that apply)

Is there any additional information regarding the minor’s health or skin that the esthetician should be aware of before treatment?

By initialing below,

I understand that MaiBeautyyCo may require a parent or legal guardian to remain on-site or present during the minor’s appointment, depending on the minor’s age, maturity, or the service being performed.

Parent/Legal Guardian Initials:

I certify that I am the parent or legal guardian of the minor listed on this form and have the legal authority to provide consent for treatment.

I understand the nature of the esthetic services requested and authorize MaiBeautyyCo and its licensed esthetician to perform the selected services on my minor child.

I acknowledge and agree that:

I have provided accurate and complete medical and health history information for my child.

I have disclosed any allergies, medications, medical conditions, skin conditions, or other information that may affect treatment.

I understand that all esthetic services carry potential risks, including but not limited to redness, irritation, swelling, sensitivity, allergic reaction, discomfort, or other unforeseen reactions.

I understand that results vary from person to person and cannot be guaranteed.

I agree to follow all pre-care and aftercare instructions provided to help reduce the risk of complications and promote the best possible results.

I understand that my consent is voluntary and that I may withdraw consent at any time prior to the service being performed.

I understand that the esthetician may refuse, modify, or discontinue treatment if it is determined that the requested service is not appropriate or safe for my minor child.

I release and hold harmless MaiBeautyyCo and its owner, Mariah Cruz, from liability for any known or unforeseen reactions or complications that may occur when services are performed in accordance with accepted professional standards, except in cases of gross negligence or willful misconduct.

By signing below I acknowledge that I have read, understand, and agree to the Parent/Legal Guardian Consent above.

Parent/Legal Guardian Signature:

Printed Full Name:

Client/Minor Signature:

Printed Full Name:

Date

Minor Consent & Authorization

Minor Information

Parent/Legal Guardian Information

Services Authorized

Health History

Skin Assessment

Parent/Legal Guardian Presence Policy

Parent/Legal Guardian Consent