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The Beauty Rezort

Consent Form

Birthday
Month
Day
Year
Gender

Please complete by checking off the applicable conditions

Pregnancy or Breastfeeding
Yes
No
Diabetes
Yes
No
Cancer (current or within the past year)
Yes
No
Heart Conditions/Pacemaker
Yes
No
Skin Conditions (e.g. eczema, psoriasis)
Yes
No
Allergies to Ingredients e.g. wax, oils, fragrances/chemicals
Yes
No
Recent Surgeries (past 6 months)
Yes
No
Thyroid Issues
Yes
No
Seizures or Epilepsy
Yes
No
High or Low Blood Pressure
Yes
No
Autoimmune Disorders
Yes
No
Any Infectious Diseases
Yes
No
Are You Currently Under The Care of a Physician?
Yes
No

Do you have a history of:

Skin sensitivity
Yes
No
Photosensitivity (sensitivity to sunlight)
Yes
No

I Agree:

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