Loading...

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT PHOTOGRAPHIC AND/OR VIDEO IMAGES

AUTHORIZATION:

I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by the practice listed below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. PURPOSE: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising REVOCABILITY: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed. NO TREATMENT CONDITIONS: I understand that the practice cannot condition treatment on whether or not I sign this authorization.

FORM PROVIDED COURTESY OF:

This form is provided by My Social Practice for general convenience purposes and does not represent legal advice. Additional compliance rules vary from state to state, country to country. If you feel like you need legal consultation in addition to what we’ve provided, be sure to consult your practice attorney including seeking advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services regulations. My Social Practice is a social media marketing company. We are NOT attorneys, and although this form is based on our own research to ensure compliance, it does not represent legal advice.

Date Signed: December 26, 2024

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

PRACTICE NAME: *
Previous discomfort, stinging and adverse reactions please tick:
Skin Disorders
Eye Infections
Watery eyes
Bell's Palsy
Allergies to latex/band aids
Are you pregnant or lactating?
Inflammation of the skin
Recent eye surgery
Hayfever
Previous reactions to eye treatments
Allergies to adhesives, glues or bonding agents
Skin Disorders
Eye disease
Blephartitis
Blephartitis
Allergies
Contact lenses
Allergies to acetone
Are you taking HRT?

Any medications:

Other relevant information:
Have you had eyelash or brow tinting, eyelash perming, eyelash extensions or semi permanent mascara applied previously?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA
Did you experience any reaction to theses treatments?*
No
Yes
YES - which treatment?
TINTING
EYELASH PERM/LIFT
EYELASH EXTENSIONS
SEMI PERMANENT MASCARA

Please provide details of this reaction:
Did you seek medical advise from a doctor or specialist as a result of this reaction?*
No
Yes

YES - what was the advise of your doctor/treatment given:

Agreement: I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted, may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!