Esthetician Consent Form

Client Name

First NameLast Name

Date of Birth

Date

Phone Number

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

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

LightStim Waiver

Low Level Light Therapy/Red Light Therapy

LightStim Precautions:

+ Extreme sensitivity to light - migraines brought on by bright light
+ Use of photosensitizing drugs
+ Melasma or hyperpigmentation exacerbated by mild warmth
+ Do not apply products that should not be exposed to mild warmth prior to LightStim treatment
+ Accutane should be discontinued for 6 months in advance of treatment
+ Clients who are pregnant must seek approval from a medical professional
+ Clients with suspicious lesions or skin cancers should consult a medical professional
+ Clients who are being treated for any type of serious health condition should seek approval from a medical professional

By signing this waiver form, I acknowledge and confirm the following:

- I have read the precautions for use of the LightStim Pro Panel, and I affirm that I do not have any conditions listed or any other issues that may cause a reaction from use of this product.

- I agree that I use this service at my own risk and will not hold SKIN BY CARIN, LLC liable for any adverse reactions.

Signature

SKINCARE FACIAL CONSENT FORM:

- I understand this entire consent and medical history form, and have answered each question truthfully. I understand that withholding information from my esthetician may result in contraindications or skin irritations from treatments received.

- I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

- I understand that there is a 24-hour cancellation policy and if cancelled within 24 hours/no show to the appointment will result in a cancellation fee.

- The skin care treatments I receive at SKIN by CARIN are voluntary and I release SKIN by CARIN from liability and assume full responsibility thereof.

Client Signature

Date