Emergency Contact Form | Fearless Femme Beauty Company

FFBC

Emergency Contact Form

Client Information

Full Name

Birthday

Month

Day

Year

Phone Number

Email Address

Address

Primary Emergency Contact

Full Name

Relationship to Client

Phone Number

Alternate Phone Number or Contact Method

Secondary Emergency Contact

Full Name

Relationship to Client

Phone Number

Alternate Phone Number or Contact Method

Health Information

Primary Care Physician's Name

Physician's Phone Number

Known Allergies (medications, skincare products, etc.)

Current Medications

Existing Skin Conditions or Concerns

Are you diagnosed with any disorders or ailments that I should be aware of, especially in the case of a medical emergency? If so, please list:

Consent and Acknowledgments

I consent to the collection and use of my emergency contact information for the purpose of ensuring my safety during esthetic treatments at Fearless Femme Beauty Company.
I agree to inform FFBC of any changes to my emergency contact details or medical information prior to future appointments.
I understand that providing accurate and complete information is essential for my safety during esthetic services.

Signature

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Date of Signature

Month

Day

Year

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