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Consent Form
First Name
Email
Select an Address
Doctor's Name
Emergency contact name
Gender:
*
Male
Female
Other
Treatment Type
*
Skincare
Nails
Waxing
Eyebrows
CACI
Last Name
Phone
Birthday
Doctor's Address
Emergency contact address
List your treatments
Medical History
Are you currently under the care of a physician?
*
Yes
No
If yes, please specify.
Do you have any allergies (e.g., latex, medications, skincare products)?
*
Yes
No
If yes, please specify.
Have you had any recent surgeries or medical procedures?
*
Yes
No
If yes, please specify.
Are you currently taking any medications?
*
Yes
No
If yes, please specify.
Do you have any chronic health conditions?
*
Yes
No
If yes, please specify.
Do you have any medical conditions?
*
None
Allergies (e.g.
Asthma
Chronic obstructive pulmonary disease (COPD)
Diabetes
Epilepsy or seizure disorder
Heart disease
High blood pressure (hypertension)
Low blood pressure (hypotension)
Blood disorders (e.g.
Thyroid disorders (e.g.
Autoimmune diseases (e.g.
Infectious diseases (e.g.
Mental health disorders (e.g.
Neurological disorders (e.g.
Respiratory conditions (e.g.
Gastrointestinal disorders (e.g.
Kidney disease
Liver disease
Cancer or history of cancer
Skin conditions (e.g.
Chronic pain conditions (e.g.
Vision or hearing impairments
Mobility limitations or physical disabilities
Recent surgeries or medical procedures
Pregnancy or breastfeeding
Other
If yes or more than one, please specify.
Skincare
Have you had any adverse reactions to facial treatments in the past?
Do you have any specific skincare concerns or goals?
Have you had any previous experience with CACI treatments?
Do you have any implanted medical devices (e.g., pacemaker)?
I understand and consent to the treatment(s) I will receive at The Grid Salon.
I acknowledge that the technician has explained the potential risks and benefits of the treatment(s).
I release The Grid Salon and its staff from any liability associated with the treatment(s) provided.
I agree to all the terms & conditions.
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