Consent Form For Treatments Involving Body Contour, High Frequency, Microdermabrasion, and/or LED

Consent Form For Treatments Involving Body Contour, High Frequency, Microdermabrasion, and/or LED
Date*

MonthDayYear
Date
Name*

First NameLast Name
Area(s) to be treated:*
I consent to and authorize Rich Revenge Beauty, LLC to perform skin treatments on me that include body contour, microdermabrasion, high frequency, and/or LED applications. I acknowledge and understand the nature and purpose of this treatment. I understand with any treatment there are certain risks involved and undesirable effects could occur. I assume these risks. Possible side effects include, but are not limited to, the following: redness, breakouts, stinging, tenderness, dry skin, lightening or darkening of the skin.
Certain health conditions prevent Rich Revenge Beauty from providing this service. Please check off any of the following health conditions you have so that we may discuss whether we can proceed with a service:*

CancerHepatitisMetal Implants/screwsHeart ProblemsDiabetesSeizuresMultiple SclerosisThrombosis/PhlebitisRecent IllnessBotoxHypoglycemiaEpilepsyThyroid DisorderPregnancyBreast FeedingMuscular ConditionsHigh/Low Blood PressureLack of normal skin sensationDermal FillersUse of Accutane/Retin-AAnabolic Steroid useMigrainesNone of the AboveOther
* By signing, I am stating that I have none of the foregoing conditions. I agree to avoid sun exposure on the treated area for 48 hours. I am at least 18 year of age. I do not have any type of electronic device in my body (Ex. Pacemaker). I agree to remove all jewelry during the treatment. I have not taken Accutane within 6 months to 1 year. I agree to avoid injectable fillers and Botox injections to the treated area for at least 14 days after the treatment. I understand Rich Revenge Beauty, LLC does not recommend this service for anyone who suffers migraine headaches. I agree to follow all after-care advice provided to me by Rich Revenge Beauty, LLC. I agree to notify Rich Revenge Beauty, LLC immediately of any concerns. I agree not to hold Rich Revenge Beauty, LLC liable for undesired outcomes arising from the service. I acknowledge this release will operate as a release for future treatments received at Rich Revenge Beauty, LLC. *

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