CONSENT FORM

Full name

Age

Email

DOB

Day

Month

Year

Contact Number

Emergency Contact Name & Number

Address

I confirm that I am 18+

Yes

Are you pregnant or breastfeeding?

Yes

No

Do you smoke?

Yes

No

Have you consumed alcohol in the last 24 hours?

Yes

No

Do you have a history of any allergy or anaphylaxis? If yes, specify:

Are you currently receiving any medical treatment? Or on any medications? If so, specify :

Are you HIV positive or immunocompromised?

Yes

No

Have you previously received any surgeries or cosmetic procedures?

Yes

No

Do you have active skin conditions or infections?

Yes

No

FOR FACIALS : Select if applies.

Used exfoliants or retinol in past 5 days?

Had any cosmetic treatments in the last 2 weeks?

Have sensitive skin?

N/A

FOR MICRONEEDLING : Select if applies.

FOR CHEMICAL PEELS : Select if applies.

FOR SKIN BOOSTERS : Select if applies.

FOR DERMAPLANING : Select if applies.

Active acne or infection?

Using exfoliants or acne medication?

Prone to irritation/razor bumps?

N/A

CONSENT, RISKS & GDPR :

- I understand the risks, benefits, and procedures.

- I confirm withholding medical info may increase risks.

- I consent to data storage (GDPR compliant).

- I consent to clinical photos being taken.

- I consent to marketing/social media use of my photos

BOOKING & CANCELLATION POLICY :

- Booking fee required to secure appointment.

- 24h notice required for cancellation/rescheduling.

- No-shows charged full amount.

- No refunds after treatment.

- Late arrivals (10+ mins) may be cancelled.

Client Signature

Signature field is empty.

Date

Day

Month

Year

Only for Practitioner Signature

Signature field is empty.

Date

Day

Month

Year