Aura Consent Forms

Personal / Contact Details

Name

Please enter Name.

Date of Birth (dd/mm/yyyy)

Please enter/select Date of Birth.

Email Address

Please enter Email Address.

Phone Number

Please enter Phone Number.

Postcode

Please enter Postcode.

Address

Please enter Address.

Therapist

Please enter Therapist.

Required Medical Information

DO YOU CURRENTLY HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS THAT COULD COMPROMISE YOUR SKIN SERVICES BEING OFFERED:
AIDS/HIV	Yes No	ECZEMA/PSORIASIS	Yes No
Cold Sores	Yes No	Hepatitis	Yes No
Herpes	Yes No	Fever Blister	Yes No
Varicose Veins	Yes No	Cancer	Yes No

Consent Form: Disclaimer

I understand a patch test is required before I have the above treatment due to a possible reaction to the product or glue. However, I am prepared to take full responsibility with this disclaimer and will not pursue any action against the therapist or salon should there be any reaction what so ever. No refunds will be given.

Please accept Disclaimer.

Have you taken accutane with the past year?	Yes No
Are you using retin a, differin, or renova?	Yes No
Are you taking any medication that make you photosensitive?	Yes No
Do you frequent tanning beds?	Yes No
Are you currently sunburnt?	Yes No
Are you diabetic?	Yes No

Waxing

Personal / Contact Details

Required Medical Information