NanoFusion and/or UltraFusion Pen Series
PROFESSIONAL TREATMENT LIABILITY RELEASE FORM. PLEASE READ THOROUGHLY AND CHECK ALL PRECAUTIONS. SIGN AND DATE.
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First Name
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Street Address
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E-mail
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example@example.com
Phone Number
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How did you find John?
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I am not pregnant
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Yes
No
I have NOT used glycolic acid for 24 hrs.
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Yes
No
I have NOT used retinol products for 72 hrs
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Yes
No
I have NOT taken Accutane in the past year.
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Yes
No
I AGREE that I currently do not use hydrocortisone
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Yes
No
I do NOT have active cold sores.
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Yes
No
I smoke.
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Yes
No
I have NOT received radiation treatments within the past 6 months.
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Yes
No
I AGREE to notify my doctor and my esthetician of any concerns.
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Yes
No
I AGREE not to wax the area of treatment for 7 days pre/post-treatments.
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Yes
No
I AGREE not to use Retin- A, or any retinol products 7 days pre/post treatments.
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Yes
No
I AGREE to follow up with any scheduled appointments.
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Yes
No
I AGREE to a minimum of 4-6 nano pen appointments.
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Yes
No
The timeline for the Nano Pen facial is every week or every other week for best results if your skin can tolerate it. Every month works as well, but the results will be slower.
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Yes
No
I understand the Nanofusion and Ultrafusion facial is a cosmetic treatment, not a medical procedure. Individual results may vary due to lifestyle and overall health.
Yes
No
The Nanofusion facial and contraindications - click any that apply
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keloid scars
eczema, dermatitis or psoriasis
history of actinic (solar) keratosis
infections (ultrafusion as well)
history of diabetes
raised moles
warts on targeted menu
blood clotting problems
active bacterial or fungal infections (ultrafusion as well)
immuno-suppression
pregnant or nursing
none of the above
history of active Herpes Simplex
history of skin cancer in designated area (UltraFusion only)
pacemaker (Ultrafusion only)
The Nanofusion facial and any potential contraindications or side effects have been thoroughly explained to me.
Yes
No
I understand that while I may see results after my first Nanofusion facial, I may require further Nanofusion and Ultrafusion facials to obtain my desired outcome.
Yes
No
I understand that outcomes will differ between individuals.
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Yes
No
I have been given the opportunity to ask any questions about the NanoFusion and UltraFusion Facial and acknowledge that all my concerns about the facial have been answered satisfactorily
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Yes
No
THIS CONSENT FORM SHALL BE VALID FOR ALL FACIALS I RECEIVE
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Yes
No
RELEASE OF PHOTOGRAPH, USE OF LIKENESS OR PRINTED QUOTES OR STATEMENTS I do hereby grant permission to Salon 544, FacescapesbyJohn, Skin Moderne, and its employees or representatives, to take and use: photographs, video and/or digital images, and printed statements for use in promotional or educational materials pertinent to Facial as follows: ·In printed publications or materials · In electronic publications or presentations · On website I agree that Skin Moderne may use such items of me for any lawful purpose, including such purposes as publicity, illustration, advertising, educational videos and web content. I HAVE READ AND UNDERSTAND THE ABOVE. Client Name:
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