Clone of Medical History + Consent Form

MEDICAL HISTORY + CONSENT FORM

VAL'S VANITY
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Shipping Address

Street Address

Street Address Line 2

CityState/ Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please take a moment to answer the following questions
Are you currently taking any medications?
Please list
Please list any other skin goals or concerns that you may have.
Have you used Retin-A, Renova, Adapa-lene, Accutane, Differen, or acids (AHAs or BHAs), or Dermatologist prescribed topicals within the last week? Please specify
Are you okay with photos/videos being posted of your service?
How did you hear about VAL'S VANITY?
Terms & Conditions

I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. By signing this I hold my esthetican harmless and nameless from any liability that may result from this treatment.
CANCELLATION POLICY

By agreeing to our policies, you understand that this appointment at Val's Vanity is reserved exclusively for you and requires a 24-hour notice for cancellation or rescheduling. Canceled or rescheduled appointments within 24 hours will incur a 100% cancellation fee and No-shows will be charged 100% of the service price.
By submitting this form, you acknowledge and agree that this document serves as proof of your consent and participation. Any attempt to dispute the transaction will be met with this evidence, confirming that you have willingly filled out and agreed to the terms stated.
Client Signature
Date

MonthDayYear
Date
Should be Empty:

MEDICAL HISTORY + CONSENT FORM

Terms & Conditions

CANCELLATION POLICY