Client Information & Medical History Agreement-Top Beauty Bar

Required Field
Personal Info
Contact Info
Emergency Contact
Doctor
Medications
General Medication Questions
Allergies (Please check all that apply)
Characters: 0/255
Do you have any of the following medical conditions? (Please check all that apply)
Surgeries

 

Skin Questions

Are you currently under the care of a dermatologist?
Do you have a history of skin rashes or erythema abigne?
Do you regularly use tanning salons or sun bathe?
Recently used self-tanning lotions or treatment?
Do you form thick or raised scars from cuts or burns?
Do you have Hypopigmentation (lightening of the skin)?
Do you have Hyperpigmentation (darkening of the skin)?
Recent tanning or sun exposure that changed skin color?
Which of the following best describes your skin type? (Please select one)
Have you ever had laser hair removal?
Hair Removal
Services or Procedure Interest
Area of Concern:

 

For Female Clients Only:

Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using contraception?
Do you consent to having before/after treatment photos posted on social media?
Please review the consent. I have read, and acknowledge these requirements. It will automatically return to the provider upon completion.

Medical Waiver

I have read, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if a protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily I understand this procedure and accept all risks and will notify Top Beauty Bar of any changes that could put my treatment at risk.

I take full liability and responsibility for all risks, undesired outcomes, or adverse events associated with the injections and will not hold the provider of Top Beauty Bar LLC liable for any unfavorable outcome or adverse event. I release Top Beauty Bar LLC, its owner, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I hereby release Top Beauty Bar LLC, Tina Videtic, and staff from all liabilities associated with the indicated procedure. The procedures to be used to treat my condition have been explained to me. Any adverse reaction should be reported immediately to the office mobile at 920-678-7709.

I have read, and acknowledge these liability requirements of my procedure.