Consent Form

Personal Information

Full Name

Date of Birth

Month

Day

Year

Are you 18 years or older?

Yes

No

Email Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Contact Number

Emergency Contact Name & Number:

Medical History & Conditions

Upload pictures of all area you would like to treat.

File upload

Medication & Skin History

Are you currently taking any prescribed medications? If yes list them

Have you refrained from using skincare products containing retinol, glycolic acid, salicylic acid, or exfoliants within the past 2 weeks?

Yes

No

Have you had any cosmetic treatments in the last 4 weeks in the treatment area (e.g., peels, laser, Botox) If yes provide details

Inkless Needling Only

How old are the stretch marks or scars? (They must be at least 6–12 months old and fully healed not red, raised, or tender.)

Consent & Understanding

I understand that the results may be very based on my skin type, lifestyle, and treatment plan

I understand temporary side effects may include redness, sensitivity, peeling, bruising, or skin irritation

I have disclosed all relevant medical conditions, medications, and allergies

I agree to follow the pre-care and aftercare instructions provided on the website

I understand that this treatment may not be suitable for me and that the practitioner may refuse treatment if it is not safe to proceed

Final Required Declaration (Mandatory to Submit)

I am receiving a model treatment at a discounted rate and I agree to Luxe Shea Body Clinic using my before/after photos and videos for social media and marketing. (Required for model bookings)

I am a regular client and I give permission for Luxe Shea Body Clinic to use my before/after photos and videos for social media. (Optional)

I do not give permission to use my photos or videos for social media.

I will inform the practitioner of any changes to my health. I understand they may postpone or refuse treatment if it’s not safe to proceed.

I have read and understood the Terms & Conditions including the treatment, risks, and aftercare. My answers are true to the best of my knowledge.

By submitting this form, you agree to our Terms & Conditions.

Signature

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