Plasma Skin Tightening and BB Glow Consent Form
Date: Client Name: Address: Profession: Tel. No: Day Eve
PERSONAL DETAILSAge group: Under 20 20–30 30–40 40–50 50–60 60+ 20–3030–4040–5050–6060+
Last visit to the doctor: GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medicalpermission cannot be obtained clients must give their informed consent in writing prior to treatment(select if/where appropriate):
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate)
ConjunctivitisSKIN TEST (select if/where appropriate):Moisture content: ExcellentGoodFairPoor Muscle tone: ExcellentGoodFairPoor Elasticity: ExcellentGoodFairPoorSensitivity: HighMediumLowSkin’s healing ability: ExcellentGoodFairPoor Skin tone: FairMediumDark Circulation: FairMediumDarkPores: FineDilatedComedonesMiliaOverall Skin Type/Condition: Current Facial Products Used: Treatment to include (select if/where appropriate):
Treatment details: (To include products/colours used, make-up chart and before and after photographs)
Client InformationPlease read carefully and only sign if you are in full agreement with its contents
I have read and understand the contradictions, pre and post care instructionsand what to expect. I certify the information in the above questionnaire is accurate and I give Ms. Fitz Glitzand Glamour and associates permission to carry out treatment. I understand that withholding and medicalinformation may be detrimental to my health and safety.
3I understand that a skin test can determine whether or not I will experience areaction to the products. However, I accept this will be inconclusive as to whether I have an allergic reactionany time in the future. I therefore waive my option to an allergy test and wish to proceed with treatment.I wish to do a patch test and will schedule this immediately after booking bycalling MS. Fitz Glitz and Glamour.
You should note that if the Technician is unsure of anything that may apply to a specific condition then theyshould not treat you without asking you to consult with your GP or Consultant. Any concerns should beaddressed before your appointment.
It is your responsibility and not that of the TECHNICIAN to consult your GP or Consultant.I hereby indemnify the TECHNICIAN against any adverse reaction sustained as a result of the treatment
Leave this empty:
Signed by Tara Fitzgerald
Signed On: October 25, 2019
If you have questions about the contents of this document, you can email the document owner.
Document Name: Plasma Skin Tightening and BB Glow Consent Form
Agree & Sign