Client Consent Form Skin sheek

Client Consent Form - Skin Sheek
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

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Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I hereby consent and authorize, blanks a Licensed Esthetician, and a SKIN SHEEK Certified Technician, to perform the following procedure blank using "Clear" by Skin Sheek.
Please acknowledge the following items:

I acknowledge that the treatment goal is for esthetic improvement, I also recognize that independent results are dependent upon age, skin conditions, and lifestyle and that there is a possibility I may require further treatments of the areas treated to obtain the expected results at an additional cost.I consent to the taking of photographs to monitor treatment resultsI consent to before and after photographs of treatment being posted publiclyI am not presently pregnant or lactatingI have not had any Botox in the past 2 weeks, or used retinoids for 3 or more daysI do not have a severe allergy to nickelI am not on any blood thinners or high doses of aspirinI have been informed of the possible risks and complications which ma include, but are not limited to, infection, hyperpigmentation, redness, edema, bruisingI understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposureI do not currently or have history or prior history of: Pace maker, keloid scarring, viral infections, auto immune diseases, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in the past 6 months.I have been given a copy of pre-care, post-care, and home instructionsI understand home care and maintenance are required to achieve optimal resultsI agree to follow the post-care, and home instructionsI understand numbing is optionalPost treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMD post treatment medical balm, it will speed healing timesI understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please list any Medical Diagnosis blanks
Please list any Medicationsblanks
Current Medical Treatments: blanks
On my own free will, I am requesting and providing my informed consent, to undergo treatment(s) I understand that this is an elective procedure, performed solely for cosmetic purposes, and is not critical to my health. I assume all risks as my own. I hereby release them from any liability, both seen and unforesees, now and forever.
Signature

Clear
Signed Date

MonthDayYear
Date
Should be Empty:

Client Consent Form - Skin Sheek