CONSENT TO ADVANCED or CLASSIC ESTHETICS TREATMENT

Client Name*

First NameLast Name

Date Of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

SKIN TYPE: Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician to determine the most appropriate way to approach your treatment(s):*

I. Very fair skin; blonde or red hair; lighcolored eyes; freckles commonII. Fair Skinned; light hair, light eyesIII. Common skin type; fair; eye and hair color varyIV. Mediterranean Caucasian skin; medium to heavy pigmentationV. Mideastern skin; rarely sun sensitiveVI. Black skin; rarely sun sensitive

Are you of Asian heritage (Class V) and/or a history of keloid scarring?*

YesNo

TECHNICIAN: Maria Sanchez, Bella Day Spa

Procedure(s): This informed consent to Treat applies to two classifications of Esthetics care: Advanced Esthetics Services and Esthetic Classic Services. Check the type of esthetic services below applicable to you. Check both if you anticipate receiving treatment under both categories. Consult your technician if you have questions about the nature of treatment anticipated for you:*

Advanced Esthetic Services. Which includes Esthetic Peels up to 40% electrology, needling/collagen induction therapy, non-invasive ultrasound, and hand-held cryotherapy.Esthetic Classic Services: Which includes Body contouring, cellulite reduction, radio frequency, and high frequency treatments.

Pre-Procedure and Aftercare Instructions: I have received, and will strictly adhere to, all pre-procedure and aftercare instructions. I understand that for those with more color in the skin, it is advised to use a lightening agent leading up to the procedure to suppress the melanin in the skin. I understand there may be an extended period of recovery following the procedure(s), and that aftercare compliance is crucial for healing, prevention of scarring, hyper-pigmentation and hypo-pigmentation. I understand that particularly avoiding sun exposure after the procedure is crucial to reduce the risk of color change and will always apply a broad spectrum SPF 25 or higher, as recommended by my technician. I understand that initially, the skin treated may be red and swollen, that fine, thin scabs may form, and that the healing process typically takes anywhere from one to three weeks. However, I am aware that in rare cases, depending on my skin sensitivity and recovery capacity, healing could take as long as three to six months.

General Risks of Procedure(s): I understand there are risks associated with my procedure, including, but not limited to: minor burns, blistering, hypopigmentation (lightening of the area), hyperpigmentation (darkening of the area), swelling, allergic reactions, bruising, scarring, pin-point bleeding, pimple-like bumps, dry skin, tingling, and other similar side effects and/or reactions. I understand these risks also include, but are not limited to, the following:

1. Scarring: This treatment can create bruising and a moderate burn or blister to the skin. Depending on treatment received, more serious side effects may include, skin indentations or subcutaneous fat loss, and open sores that lead to infection.

2. Pigmentation: The treated area may become either lighter (hypo-pigmented) or darker (hyper-pigmented) in color. This is rare and is usually just temporary, however may become permanent.

3. Infection: Although infection following this treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes Simplex virus infections around the mouth can occur following a treatment, even if there is no past history of Herpes Simplex virus infections in the mouth area. Clients with a history of Herpes Simplex virus in the treated area are encouraged to seek preventative therapy. Should any type of skin infection occur, additional treatment, including antibiotics, may be necessary.

4. Skin tissue pathology: Only clearly benign pigmented lesions can be treated. A doctor’s clearance should be obtained in the case of this type of treatment. Treatment directed at abnormal lesions can cause malignant cells to develop and laboratory examination of the tissue specimen may not be possible.

5. Allergic reactions: Due to skin surface disruption, irritation and histamine reactions may occur resulting in itching, dermatitis, or other forms of sensitivity. In rare cases, local allergies to topical preparations have been reported.

I certify that this consent has been fully explained to me, that I have read the above paragraphs, and that I elect to receive the advanced esthetic procedure(s) above. I understand the various risks associated with the procedure(s) and importance of properly following pre-procedure and aftercare instructions to minimize risks.

Client Name*

First NameLast Name

Date*

Signature*

NOTICE: Occasionally, unforeseen problems may occur, and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.

Technician Signature