Treatment Readiness

Consent

FACIAL TREATMENT CONSENT FORM

Glo With Ally

FACIAL TREATMENT CONSENT FORM

First Name

Last Name

I, , agree to having to undergo this treatment/procedure after having the treatment details and nature of the treatment along with risks and hazards involved by qualified esthetician Ally Gould.

I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle factors and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have also, to the best of my knowledge given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I understand and agree to the after-care instructions, provided by the certified esthetician for the use and care of my lashes and brows after having the treatment brow lamination/tint/lash lift performed. I realize and accept the consequences of failure to adhere to these instructions may cause no to little results obtained.

Is this your first time recieving this specific service at Glo With Ally

Yes

Have there been any changes to your health history, medications, skincare routine, allergies, pregnancy status, or any other information that may affect your treatment since you last completed your consultation form.

Yes

If you answered 'Yes,' please complete a new consultation form for this service to ensure your information is current and accurate.

Please check the circle to confirm your understanding

I have read and understand this agreement and all information detailed above. I understand the procedure and accept the risks. I do not hold the esthetician, Ally Gould, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by treatment performed today.

Accuracy Declaration

I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my treatment. I agree to notify Glo with Ally of any changes to my health, medications, skincare products, or other relevant information before receiving future services.

Type Full Name to Sign

Date of Signature

I agree to the terms outlined above.

Yes

By checking the validation box and typing your name, you acknowledge that you have completely read and fully understand the above agreement, and that your typed name stands as your legally binding digital signature under the US ESIGN Act.