Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:
* I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Customized Facial.
* I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved.
* Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
* I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
* I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
* I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
* I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I understand this is a cosmetic procedure with risks and potential side effects, and I voluntarily wish to have the services provided with knowledge of the potential side effects. I understand that any false information I have provided may lead to undesirable consequences and affirm I have truthfully discussed my personal and medical history to my esthetician. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects. I understand that the esthetician does not diagnose illness, disease, or any other physical or mental conditions. I have read the above information and if I had any concerns, I have addressed them with my esthetician. I give permission to my esthetician to perform the procedure we have discussed and will hold them harmless from any liability that may result from this treatment. I have given an accurate account of all known allergies or prescription drugs or products I am currently ingesting or using topically. This waiver will be kept on file and will apply to each and every facial service I receive today and in the future. By signing this document state that I have read, agree and understand the terms herein and voluntarily have accepted the service and any potential risks that may be associated with the service.I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.