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STUDENT MODEL RELEASE
12
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1
Full Name:
*
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First Name
Last Name
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2
Email
*
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Please provide a valid email address to receive appointment confirmation and updates
example@example.com
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3
Phone Number
*
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Please provide a valid phone number in case we have questions about your health / skin history
Area Code
Phone Number
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4
I agree to receive the following treatment(s) from a Student Trainee in exchange for a complimentary or significantly reduced service cost:
*
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(SELECT ALL THAT APPLY)
Microneeding & Dermaplane
CryoSlimming
Permanent Make Up
Other
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5
Which services are you willing to receive as a model:
PMU Brows
PMU Lip Blushing
Dermaplane
ProCell
Microneedling
Cryo Slimming
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6
I acknowledge that the student technician is someone learning Advanced Aesthetic services and does not have the same skill level as an experienced or master Aesthetician. I am aware that results may vary, or be imperfect. I have had the opportunity to ask questions about the treatment(s) and technicians performing my service. I'm satisfied with the information I've received and am ready to schedule an appointment.
*
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Yes, I understand and agree.
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7
I understand that standard booking policies apply to my model appointment; a non-refundable deposit may be required to hold my spot, and I must complete an online check-in:
*
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Yes, I understand and agree.
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8
I understand I MUST return to the spa for an "after" (healed) photo, and touch-up (if PMU service) in 6-8 weeks after treatment. I agree to schedule a follow up appointment at the time I receive my service.
Yes, I understand and agree.
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9
The following are CONTRAINDICATIONS for receiving a service as a model. Please check ALL that apply:
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10
Please explain your contraindication further (or N/A for none)
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11
Are you currently using, or previously used any injectable semaglutide or tirzepatide medications? (Ozempic, Mounjaro, Wegovy, Rybelsus etc)
*
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**Use of these weight loss injections causes skin changes and inflammation which may increase chances of side effects from some aesthetic treatments. Please always notify your provider when you are using these medications. **
YES
NO
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12
Please check each box to confirm and agree:
*
This field is required.
A beginner technician may be conducting my service for hands on instruction
Touch ups or additional treatment may be required at my own expense
There is no warranty and a final result is not guaranteed
There may be risks and hazards related to the performance of the procedure
There is the possibility of discomfort, bleeding, swelling and allergic reactions
I must not take blood thinning medications (including pain killer) 24 hrs before/after service
I should not have caffeine or alcohol within 48 hours of the treatment
I should stop taking supplements one (1) week before the appointment
I must not wax in the area 2-3 days before the appointment
Tattoing is considered permanent, but may fade over time
I understand photos/ video will be taken during my procedure and used in marketing
I understand if I am on my menstrual cycle during the service, there may be greater discomfort.
It is my responsibility to inform my technician of all medications being taken by me, and to confirm on the day of treatment that there have been no changes in my health or medical/ cosmetic history since the completion of this form.
I have been given the opportunity to ask questions, I have read and fully understand the questions, terms, and disclosure conditions of this Consent Form. This form was completed by me, and all entries and information in it, are true and complete to the best of my knowledge.
I will sign additional treatment consents 72 hours before my appointment if requested
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13
PHOTO REQUIRED: Include a clear photo of your face with no makeup, in good lighting.
(Optional)
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14
SIGNATURE: I wish to participate as a training model for Eclat Clinical Esthetics LLC "ECLAT" aka ÉCLAT Skin Confidence Spa and ECLAT Academy of Advanced Esthetics. In consideration for complimentary or reduced price of my treatment(s), I hereby grant permission to ÉCLAT to use any photographic treatment records for the purposes of advertising or promotion without any additional compensation to me. I indemnify and hold harmless ECLAT and its governing officers and employees from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs or judgments including, but not limited to, claims based on negligence that may arise in connection with the services performed on me.
*
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15
Please click "SUBMIT" to complete this form. Thank you!
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