MODEL CONSENT

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Full Name:* This field is required.
First Name
Last Name
2
Email* This field is required.Please provide a valid email address to receive appointment confirmation and updates
example@example.com
3
Phone Number* This field is required.Please provide a valid phone number in case we have questions about your health / skin history
Area Code
Phone Number
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I wish to participate in the ECLAT treatment model program to receive the following service(s) at up to 75% OFF the standard prices in exchange for being photographed or filmed during treatment for marketing purposes:* This field is required.Check all that apply
Dermaplane + Microneedling $145. (Reg.$350)
Microneedling + DMK $224 (Reg. $450)
Microneedling + MDX Exosomes $270 (Reg $500)
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Which services are you willing to receive as a model:
PMU Brows
PMU Lip Blushing
Dermaplane
ProCell
Microneedling
Cryo Slimming
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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.
Yes, I understand and agree.
7
I understand that standard booking policies apply to my model appointment; a $75 - $100 non-refundable deposit is required to hold my spot, and I must complete a treatment release and online check-in:* This field is required.
Yes, I understand and agree.
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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The following are CONTRAINDICATIONS for receiving a service as a model. Please check ALL that apply:* This field is required.
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Please explain your contraindication further (or N/A for none)* This field is required.
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Are you currently using, or previously used any injectable semaglutide or tirzepatide medications? (Ozempic, Mounjaro, Wegovy, Rybelsus etc)**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. **
YESNO
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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 must not wax in the area 2-3 days before the appointment
I understand photos/ video will be taken during my procedure and used in marketing
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.
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PHOTO REQUIRED: Include a clear photo of your face with no makeup, in good lighting.(Optional)
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SIGNATURE: I wish to participate as a training model for Eclat Clinical Esthetics LLC "ECLAT" aka ÉCLAT Skin Confidence Spa. 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.* This field is required.
Clear
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Please click "SUBMIT" to complete this form. Thank you!
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