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  • Facial Client Intake/Consent Form

    CONFIDENTIAL.
  •  - -
  • Format: (000) 000-0000.
  • Medical History

  • Your Skin

  • By Submitting AND Signing this form, I acknowledge,consent and agree to the following: I give my permission to receive facials and skin care treatments. I consent the the taking of photographs to monitor treatment effects, as desired or recommended by my esthetician. I understand that results are not guaranteed and for maximum results, more than one service may be required. The rate of improvement of my skin depends on my age, skin type and condition. I have been informed of the possible negative reactions and the expected sequence of the healing process. (Drying, irritation,redness, and peeling of skin) I understand that the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks,complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes and previous verbal or written disclosures. I understand that the esthetician does NOT diagnose illnesses or injuries or prescribe medications. I have clearance from my physician to receive facials and skin treatments. I acknowledge that if I'm allergic to one or more ingredients in the products I may experience allergic reactions. I acknowledge that if I fail to use minimal sunscreen ( SPF45) I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure. I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should AVOID the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.  I understand the importance of informing my esthetician of all my medical conditions and medications I am taking and to let my esthetician know about any changes that may happen. I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly. I understand that my esthetician may terminate the session at any given time. If I have any questions or conversant I will address these with my esthetician before seeking outside resources. I have been given the change to ask questions about the session and my questions have been answered. I consent (to the best of my knowledge) that the answers I have given are true and that I have not withheld and information that may be relevant to my treatment. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my esthetician.  I therefore, Release Dessthetics and its staff from all and any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products. 

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