Aesthetics Model Consent Form

Model's Details

Model Name: *

Model Email: *

Model Contact Number: *

Model Date of Birth: *

Treatment Type: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Medical History

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Are you currently taking any medications? *

Please provide more detail: *

Do you have any allergies? *

Please provide more detail: *

Do you have any medical conditions? *

Please provide more detail: *

Are you currently, or possibly may be, pregnant? *

Additional Notes:

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I consent to acting as a model for the purpose of training practitioners / aestheticians / therapists (under supervision) in the administration of the treatment named above.

The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction.

I have signed a separate product specific consent form.

I fully understand the above and consent to the specified treatment(s) to be carried out.

Model's Signature: *

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Trainer's Signature: *

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