I have voluntarily elected to undergo this service.
Although it is impossible to list every potential risk and complication, I have been informed of the most commonly associated risks and contraindications with this service. I have had the opportunity to ask any questions I may have prior to my service. I, therefore, consent to not hold my esthetician or Skin Society Hawaii LLC liable for any issues, damages, or side effects that may occur.
I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle, and that there is a possibility I may require further services in the treated areas to obtain the expected results, at an additional cost.
I have read and understood all available pre and post-treatment care instructions, and acknowledge how medically important it is to follow these instructions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.
To the best of my knowledge, I have also given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I assume responsibility, and if I’ve failed to mention anything to my esthetician regarding my medical condition/history - they will not be held liable if any issues, complications, or damages arise. If my medical status changes, I will notify the company prior to my service.
I give consent to take photos of me for the purpose of client records, company education, marketing, and advertising. I also understand my personal information (such as name, email, phone number, credit card, etc.) will be held on file by the company. I understand the company may contact me through text, email, and social media for the purpose of business, marketing, and advertising. I understand I have the option to opt-out of any advertising and marketing at any time by doing so electively on those channels.
CONSENT TO ADVANCED or CLASSIC ESTHETICS TREATMENTS -
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.
I elect to receive the esthetics procedure(s) indicated above. I declare that I am over the age of 18, not under the influence of drugs or alcohol, not pregnant or nursing, not on blood thinners or blood pressure medication, and am not an insulin- dependent Diabetic. I understand that if I am under the age of 18, Parental Consent is required for me to obtain these procedures. Under no circumstances may I have these services if I am under the age of 14. I represent that the stated date of birth is truthful on this form.
I understand that many medications and some diseases and disorders may either contraindicate me for treatment or affect the results. I understand I should continue taking my medications, and tell my technician about all prescription and non-prescription drugs, supplements, topically applied products, eye drops, etc. that I use or take. I understand that due to the nature of this treatment, results cannot be predicted, and I acknowledge that no guarantees have been made as to the results that may be obtained.
Warning: Treatment is not available to clients who are on Accutane. Clients using anticoagulants must disclose this to the Technician, as treatment may need to be modified to mitigate additional risk associated with the use of these drugs. Clients with a pacemaker, internal defibrillator, or metal implants must disclose this to the Technician as this may contraindicate them for treatment. For women of childbearing age: You confirm that you are not pregnant and do not intend to become pregnant during the course of treatment. Furthermore, you must keep your technician informed should you become pregnant during the course of treatment.
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 have read the above paragraphs, and that I elect to receive the advanced esthetic procedure(s) indicated above. I understand the various risks associated with the procedure(s) and the importance of properly following pre-procedure and aftercare instructions to minimize those risks.