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Million Dollar Facial

Let us do this part

Today's Date:

Mon Dec 2 2024 04:28

Please read and answer

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Eaten*

Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.

Medical History*

Pregnant/Breast feeding Heart conditions/pacemakers Diabetes Skin disorders Kidney problem Swelling/oedema Cancer Limitation of movement/arthritis Epilepsy Prone to keloid scaring Hormone imbalance Stroke Claustrophobia Hepatitis Metal plates/pins/piercings Recent scar tissue/surgery Respiratory problems Allergies High/low blood pressure Operations within the last 6 months Any other medical ailments/medications?

Risks*

That I have been fully informed of the risks, associated with getting a Million Dollar Facial. I understand that these risks, known and unknown, can lead to injury, including but not limited to scarring, keloiding and allergic reactions. Having been informed of the potential risks associated with getting a Million Dollar Facial, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.

Release*

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Beauty Therapist from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Beauty Therapist at Milly's Beauty Bar.

I understand*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.

Photography*

I release all rights to any photographs taken of me and the Beauty Therapist and give consent in advance to their reproduction in print or electronic form.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Physician Information

Enter your physician or medical practitioner's contact details.

Name:

Contact:

Address: