I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement.
MEDICATIONS:
HISTORY
FOR OUR FEMALE CLIENTS:
I certify that the preceding medical, personal and skin history statements are true and accurate. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
CLIENT INFORMATION & LASER/MEDICAL HISTORY
In order to provide you with the most appropriate laser treatment we need you to complete the following questionnaire. All information is strictly confidential.
MEDICAL HISTORY
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
By submiting this form, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.