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Informed Client Consent Form -Form Fill

Section One
Q1

NAME
Q2

DATE of BIRTH

Date
Q3

Address

ADDRESS
Q4

Address
Q5

Address

CITY
Q6

Address

ZIP
Q7

PHONE
Q8

EMAIL
Q9

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial
Q10

treatment/procedure
Q11

requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
Q12

advertising, and promotional purposes.
Q13

Client Name (Printed)
Q14

Client Name Signature
Q15

Date

Date
Q16

Technician/Esthetician