Personal InformationName First Last Phone numberEmail address Date of Birth YYYY slash MM slash DD Procedure InformationType of procedureDate of treatment DD slash MM slash YYYY Technicians nameMedical InformationDo you have any known allergies? Yes No List of allergiesAre you currently taking any medications? Yes No List of medicationDo you have any chronic medical conditions? Yes No e.g., diabetes, heart diseaseList of skin conditionsAre you currently under the care of a physician? Yes No Acknowledgments I acknowledge that I am receiving a body contouring procedure (hereafter referred to as "the Procedure") at The Bomb Aesthetics. I understand that results may vary from person to person and are influenced by individual body characteristics. There is no guarantee as to the outcome of the Procedure. I acknowledge that the technicians at The Bomb Aesthetics are not medical professionals but are trained and certified in body contouring techniques. I understand that allergic reactions to the products and equipment used in the Procedure are possible. While rare, it is impossible to determine beforehand if I might have an allergic reaction. Therefore, I absolve The Bomb Aesthetics and its technicians of any liability should I experience an allergic reaction. I have been informed that I have the option to request a patch test to check for potential allergic reactions prior to undergoing the full Procedure. If I choose to forego this test, I accept full responsibility for any adverse reactions that may occur. I acknowledge that healing and results times can vary based on my individual health, body type, and adherence to aftercare instructions. I understand that post-procedure care is crucial to the success of the Procedure and agree to follow all aftercare instructions provided by the technician. I have been fully informed of the risks associated with the Procedure, including, but not limited to: bruising, swelling, discomfort, temporary skin discoloration, infection, and dissatisfaction with the final results. I acknowledge that certain medical conditions and medications may affect the Procedure’s outcome. It is my responsibility to disclose all known medical conditions and medications to the technician before the Procedure. I understand that multiple sessions may be required to achieve the desired results and that these additional sessions will incur extra charges. I understand that The Bomb Aesthetics does not offer any refunds for the Procedure under any circumstances. I understand that The Bomb Aesthetics and its technicians cannot be held responsible for any costs associated with medical treatment I may require in the event of an adverse reaction. Consent I have read and understood the information above. By signing below, I consent to the eyebrow extensions treatment and release The Bomb Aesthetics from any liability related to the procedure.Clients SignatureDate DD slash MM slash YYYY Technicians signatureDate DD slash MM slash YYYY
