online mobile client waiver - WaiverElectronic

Client Consent for Treatment Form

Name: * Please enter your name.

Date: *

Please enter valid date.

Address: *

Please enter address.

Phone: * Please enter your phone number.

E-Mail: * Please enter your email.

How did you hear about us? * Please enter your answer here.

I, name listed as above, consent and authorize a Service Technician to perform the following procedure/services on me.

Services: * Please enter your answer here.

Are you currently on any medications? If yes, please list: * Please enter your answer here.

Surgeries/Cosmetic Procedures: Please enter your answer here.

Do you have a latex allergy?: *

Yes

Please select at least one choice above.

Are you currently using any Retinol products? *

Yes

Please select at least one choice above.

Comments/Concerns: Please enter your answer here.

Initials

The nature and purpose of the treatment(s) have been explained to me. Any questions I have regarding this treatment have been answered to my satisfaction. * Please click the yellow area and provide your initials here.

Initials

I understand that with any treatment, certain risks are involved and that any complications or side effects from known or unknown causes may occur. I freely assume these risks. * Please click the yellow area and provide your initials here.

Initials

I have formally stated, in detail, all surgeries, medications, illnesses, allergies/allergic reactions that may cause side effects or other complications to the services that will be performed. * Please click the yellow area and provide your initials here.

I consent to the use of photos for marketing materials.

Yes

Please select at least one choice above.

Initials

I am at least 18 years of age or I have parental consent as co-signed below. * Please click the yellow area and provide your initials here.

Initials

All services are final, no refunds, no exchanges and no exceptions. We always want you to love your service! At Dollface, we guarantee our lash work for a week. If there is ever a question or concern, please reach out to us asap. * Please click the yellow area and provide your initials here.

Client Signature: *

Click to sign

Please sign here.

Date: *

Please enter valid date.

Co-Signature:

Click to sign

Please sign here.

Date:

Please enter valid date.

The online mobile client waiver gets the focus of the business owners in the US.

Client Consent for Treatment Form