Plasma Skin Tightening and BB Glow Consent Form


Date:  
Client Name:  
Address:  
Profession:  
Tel. No: Day  
Eve  

PERSONAL DETAILS
Age group:  

Lifestyle:

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 medical
permission 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)

2

Conjunctivitis
SKIN TEST (select if/where appropriate):
Moisture content:
Muscle tone:
Elasticity: 
Sensitivity:
Skin’s healing ability:
Skin tone:   
Circulation: 
Pores:
Overall 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 Information
Please 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 instructions
and what to expect. I certify the information in the above questionnaire is accurate and I give Ms. Fitz Glitz
and Glamour and associates permission to carry out treatment. I understand that withholding and medical
information may be detrimental to my health and safety.

3
I understand that a skin test can determine whether or not I will experience a
reaction to the products. However, I accept this will be inconclusive as to whether I have an allergic reaction
any 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 by
calling MS. Fitz Glitz and Glamour.

You should note that if the Technician is unsure of anything that may apply to a specific condition then they
should not treat you without asking you to consult with your GP or Consultant. Any concerns should be
addressed 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

Signature Certificate
Document name: Plasma Skin Tightening and BB Glow Consent Form
Unique Document ID: 94499d02ff0e70edc9b830bda95454ce930463c5
Timestamp Audit
October 25, 2019 5:39 pm GMTPlasma Skin Tightening and BB Glow Consent Form Uploaded by Tara Fitzgerald - tara.fitzgerald3@aol.com IP 24.251.80.44, 127.0.0.1