Section 1: Client Information

Your First Name *

Your Last Name *

Your Email *

Your Emergency Contact Name

Emergency Contact Phone

Section 2: Medical Disclosure

Please answer the following:

01. Are you currently pregnant or breastfeeding? *

Yes

02. Do you have any allergies (e.g., latex, lidocaine, skincare ingredients)? *

Yes

03. Are you currently taking any medications (oral or topical)? *

Yes

What are the medications? *

05. Are you currently under the care of a physician or dermatologist for any skin conditions? *

Yes

Section 3: Treatment Consent

By signing below, I understand and agree to the following:

I voluntarily consent to receive the aesthetic treatment(s) selected.
I understand the nature, purpose, potential benefits, and possible side effects or risks of the procedures.
I confirm that I have disclosed all relevant medical conditions, medications, and allergies.
I release Lumiz Aesthetics and its technicians from any liability for outcomes due to undisclosed information.
I acknowledge that results may vary and no specific outcome is guaranteed.
I understand pre- and post-treatment care instructions will be provided, and following them is my responsibility.

I consent to before/after photos being taken for documentation and/or marketing purposes (optional): *

Yes, you may use photos for marketing

No, photos for internal documentation only

Section 4: Your Consent

Draw Your Client Signature *

Enter Date *

Customer Waiver Form