Melodie Girard Aesthetics – CONSENT AND RELEASE FORM

I, {firstName} {lastName} (“Participant”) hereby request and grant permission to, Melodie

Girard (“Aesthetician”) of Melodie Girard Aesthetics located at 113 W. Mission St. Suite E, Santa Barbara, CA 93111, to provide me with aesthetic consultation and treatment, for one or more of the following cosmetic treatments or procedures: electrolysis, chemical peel, microdermabrasion, microneedling, facial, waxing, LED light therapy, ultrasound cavitation, dermaplaning, cosmetic tattoo, microblading, plasma rejuvenation (collectively hereinafter (“Cosmetic Procedures”) that may be

performed at the aesthetic office located at the address provided above.

I understand that administration of Cosmetic Procedures have certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I acknowledge that participants should refrain from tanning and/or direct sun exposure within 48 hours of receiving certain Cosmetic Procedures. I

also understand and acknowledge that participants should not have any skin “peels” within one week after Cosmetic Procedures. I understand and acknowledge that some skin conditions including aged or delicate skin, or medications, can cause skin irritation or rashes to the participant receiving Cosmetic Procedures and, in some cases, the removal or lift of the participant’s skin. I have received and reviewed information about the services I am seeking. I know that risks include but are not limited to: Skin rash,

pimples, inflammation, burns, blisters, prolonged skin sensitivity, permanent scarring, hyperpigmentation and hypopigmentation, allergic reaction. I knowingly and voluntarily assume all risks associated with receipt of the Cosmetic Procedures.

It has also been explained to me, and I understand that there are risks associated with the administration

of any Cosmetic Procedures. These risks include but are not limited to: mechanical failure of equipment or tools, negligence of any kind, reactions to lotions or topically applied ointments, disease from contaminated needles, death, dismemberment, or personal injury. Despite these risks, I knowingly and voluntarily request the Cosmetic Procedures be administered to me and I hereby assume all risks associated with administration of such Cosmetic Procedures.

In consideration of being provided with the particular Cosmetic Procedures performed, for which I have assumed the risks, and as a condition to receiving the Cosmetic Procedures, I do hereby release, waive, and discharge from and against any and all actions, costs, claims, losses, expenses and/or damages,

including attorneys fees, arising from any rights or claims I might have now or in the future for any injuries in any manner resulting from any consultation regarding and/or treatment of Cosmetic Procedures, including those claims based on any released parties alleged or actual negligence or gross negligence, breach of any express or implied warranty, breach of contract, or breach of any statutory or other duty of care, or mistakes or errors in judgment of any kind. No refunds will be provided.

I agree that any and all claims for injury arising from my receipt of the Cosmetic Services shall be governed by California law and exclusive jurisdiction of any claim shall be in the Santa Barbara County, California. In the event any provision of this document is found to be unenforceable, that finding shall not affect the enforceability of any other provision hereof.

I HAVE CAREFULLY READ THE FOREGOING LIABILITY RELEASE, I UNDERSTAND ITS CONTENTS, AND I AM AWARE THAT BY SIGNING BELOW I AM RELEASING LEGAL RIGHT THAT I OTHERWISE HAVE AND I AM ASSUMING ALL RISKS OF THE COSMETIC PROCEDURES THAT I HAVE RECEIVED, OR WILL RECEIVE.