In compliance with Club Beauty Privacy Practices, this form will allow you to designate an individual(s) to whom Club Beauty may disclose your protected health information. This may include individually identifiable information related to past, present, or future appointments, and medical or financial information. This does not include information relating to mental health treatment or HIV test results as releasing that information requires your separate written consent. If you do not want to designate an individual(s) to receive your protected health information, indicate “none” below.

By signing below, I acknowledge that I have had full opportunity to read and consider the content of this authorization and understand that my protected health information may be disclosed to the individual(s) listed above. I understand that designating the individual(s) listed above does not exclude Club Beauty from disclosing my protected health information as outlined by Club Beauty’s Privacy Practices, (a copy will be provided upon request). I understand that I have the option to revoke this authorization at any time, and then execute a new authorization. I also understand that unless revoked in writing by completing a new authorization form, this authorization will remain in effect until I choose to revoke it.
Please review our COVID-19 safety guidelines when booking your appointment!
Please Wear A Mask – We will have extra masks upon entry. All artists will be wearing masks during
treatments. We also ask that all clients wear their masks through the duration of their treatment, unless their
treatments involve their lips or facials.
DO NOT Bring Anyone With You – We ask that you please do not bring family, children or friends to the
Sanitize Upon Entry – We will have hand sanitizer so you may sanitize before and after your appointment.
Limit Conversation – During this time, we ask for minimal contact and conversation to stop the spread of
Thank you for understanding and taking the proper measures in keeping everyone safe!