Lash Lift and Tint Consent Form
AUTHORIZATION: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations.
PURPOSE: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising
REVOCABILITY: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed.
NO TREATMENT CONDITIONS: I understand that the practice cannot condition treatment on whether or not I sign this authorization.
COPY PROVIDED: A copy will be emailed to you in a PDF format once you have successfully completed this form
IF PERSONAL REPRESENTATIVE Name
Relationship To Patient
IF PATIENT IS A MINOR Name
IF PERSONAL REPRESENTATIVE Parent or Legal Gardian
FORM PROVIDED COURTESY OF This form is provided by My Social Practice for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like you need legal consultation in addition to what we’ve provided, be sure to consult your practice attorney including seeking advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services regulations. My Social Practice is a social media marketing company. We are NOT attorneys, and although this form is based on our own research to ensure compliance, it does not represent legal advice.
INDEMNITY FORM / CLIENT CONFIDENTIALITY FORM
You are a
Date of Birth:
Previous discomfort, stinging and adverse reactions please tick:
Any medications: Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?
Did you experience any reaction to theses treatments?
Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?
What was the advise of your doctor/treatment given:
Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s). I have read all information provided:* Please sign and date below to indicate that you have read all statements and understand: I, the client herein signed, certify that I have read and had explained to me and fully understand the above waiver and release form. I have provided information regarding my health and medications taken to the best of my knowledge, the client herein signed, for the purposed of documentation, hereby consent to any “before and after” photographs, which may or may not be used for the purposes of advertising. *
RESERVATION & CANCELLATION POLICY:
CREDIT CARD IS REQUIRED FOR ALL APPOINTMENT INCLUDING VOUCHER, GIFT CERTIFICATES AND PREPAID SERVICE. 48 hours ADVANCE NOTICE OF CANCELATION REQUIRED. LESS THAN A 48 hours NOTICE WILL INCUR A 50% FEE. NO SHOWS WILL BE CHARGED 100%* *
Leave this empty:
Your legal name
Signed by Theresa Fisher McCloy
Signed On: October 1, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Lash Lift and Tint Consent Form
Agree & Sign