Prior to receiving treatment, I have been candid in revealing any and all medical history and/or conditions that may have bearing on this procedure. Additionally,
I confirm that:
- I am not pregnant or breastfeeding.
- I do not have any known malignancy, autoimmune disorder, neurological or neuromuscular disease.
- I do not have any metal implanted devices. These include pacemakers, defibrillators, metal heart valves, large metal dental implants, artificial metal joints, metal plates.
- I do not currently have a cold sore/fever blister or canker sore. If I have a history of these, I have been advised to take necessary medication, such as Valtrex, to prevent an outbreak.
- I do not have a history of thrombosis or any blood clotting disorders.
- I do not have epilepsy or a seizure disorder.
- I have no known heart conditions.
I understand that:
- This is a cosmetic treatment and that no medical claims are expressed or implied.
- To achieve maximum results, several treatments are required.
- There are no guarantees as to the results of this treatment, due to many variables, such as age, condition of skin, sun damage, smoking, climate, etc.
- I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment.
- I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk.
- I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.
- I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure.
- I understand that it is imperative to my health that I disclose all of the information requested in the Facial Consent Form.
- Degree of improvement is variable and, occasionally there is no improvement and another form of treatment may be required.
- I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
- I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
- I consent to “before and after” photographs for the purpose of documentation.
I understand that if I have any concerns, I will address these with my skin care provider. I give permission to my skin care provider to perform the microcurrent procedure we have discussed, and will hold Skin Facial Bar LLC and its employees/ skin care providers harmless and nameless from any liability that may result from this treatment. Because the skin care provider must be aware of any existing physical conditions that I have, I have accurately provided all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my skin care provider know. I understand that there shall be no liability on the skin care provider or Skin Facial Bar, LLC for any services rendered. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care provider immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.