I (print your name)_______________________________ certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.I understand that there is a possibility of short-term side effects from the treatment. I could experience edema (swelling), prolong redness in the area treated as well as slight heat discomfort/tingling. These side effects have been fully explained to me during my consultation/treatment.I acknowledge that patient results may vary depending on many factors including, but limited to, medical history, and individuals response to treatment; patient compliant with pre and post treatment instructions or changes in medical condition prior to, during or after treatment has been completed.I agree (if required/requested) to the photographing of appropriate portions of my body for medical scientific or educational purposes, provided they do not reveal my identify.I understand that the treatment protocol involves a series of treatments with a specific protocol involved along with a fee structure associated to this series. I agree to follow this treatment protocol and fee structure as it was explained to me.It has been explained to me by my esthetician, during my consultation, in a way that I understand: a. The above treatment or procedure to be undertakenb. There are risks to the procedure/treatment proposed and I have been explained on what those risks arec. There is no guarantee on the final results that I will obtaind. The decision to proceed is based solely on my expressed desire to do so and that I have informed the staff regarding any current or past medical condition, disease or medication that I am takinge. Any questions I have have asked have been answered to my satisfaction