Client consent form

Client consent form

Please fill prior to your appointment
Please note:

If you have previously had treatment at The Beauty Room, and/or previously filled a client waiver form, you do not need to complete the form again. Please contact us with any new concerns.
Client Information
Name*

First NameLast Name
Age*
Birth Date*

DayMonthYear
Date
Phone Number*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityCounty

Postcode
What treatment are you having today?*

WaxingManicure/pedicureMassageEyelash/eyebrow tintingMakeup applicationElectrolysis
Do you have or have had any of the following health conditions?*

Eczema, acne or psoriasisHeart disease/conditionHepatitis or HIV infectionEpilepsy/seizuresHigh or low blood pressueNeurodevelopmental disorder/learning disabilityScarringOther
Are you pregnant or nursing?*

YesNo
Have you had any recent injuries or surgery?*
If yes, please specify.
Do you have any allergies?*
If yes, please specify.
Have you been to The Beauty Room before?

YesNo
Have you had this treatment before?

YesNo
Please inform us of anything else you'd like us to be aware of prior to your treatment.
Acknowledgment and Waiver
Disclaimer:*

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation.
Signed Date

DayMonthYear
Date
How would you prefer us to contact you (if needed)?
Client Signature*

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Client consent form

Please note:

Client Information

Acknowledgment and Waiver