Radio Frequency Consent Forms

Radio Frequency Intake Form
General Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
Email*
example@example.com
Occupation
Emergency Contact Name
Phone#
How did you hear about us?

Skin Care History
Do you receive Botox, or filler?*

YesNo
Have you had any previous facial treatments?*

YesNo
If yes, please list:
(Female clients) Are you currently pregnant or nursing?

YesNo
When was the first day of your last menstrual cycle?

Radio Frequency Consent Form
Radio Frequency is a non-invasive cosmetic procedure to help smooth, tighten, contour skin, and temporarily reduce the appearance of cellulite. It can help treat sagging skin, lack of definition in the jawline, loose jowls, sagging neck skin,wrinkles, and fine lines. Radio Frequency uses electrical pulses to target and penetrates the under layer of skin using heat to stimulate collagen. The outer layer of skin is cooled during the process to avoid damage. Please read and initial the statements below:*

I understand that during the radio frequency procedure I will feel a brief deep heating sensation.I understand that an exact result cannot be predicted and I acknowledge that no guarantees have been made as to the results that may be obtained.I understand that side effects are rare but can include swelling, redness, bumps, minor burns, and blisters on or around the treated area.I understand that alternative methods to radiofrequency include Botox, dermal fillers, laser treatments, and surgery.I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.I confirm that I do not have an inserted pacemaker, internal defibrillator, or metal implants.I confirm that I am not pregnant or breastfeeding.I agree in the event of nonpayment, to bear the cost of collection, and/ or court cost and reasonable legal fees, should this be required.I understand that no refunds are made for products, service packages, or pre-paid treatments once they are purchased

Consents
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

By signing below, I certify that I have read this entire document and that I agree to all its provisions. I certify that I have had the opportunity to ask questions my questions regarding the procedure have been answered satisfactorily. I fully understand the treatment conditions, the procedure, and possible side effects and I accept the risks. I hereby give my consent and authorization and release this establishment and its agents from any and all liability associated with the procedure. If pre and post-treatment photos and/or videos are taken of the treatment for record purposes, I understand that these photos will be the property of the attending doctor or nurse.
Take Photo*
Name Printed*
Signature*
Geolocation*
Should be Empty:

Radio Frequency Intake Form

Medical History

Skin Care History

Radio Frequency Consent Form

Consents