Skin Sheek Clear

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date

I hereby agree to the following. I am allowing photos/videos of my treatment and/or treated areas to be used for the purpose of monitoring my progress.

I give permission for my photos/videos to be used for advertising. At my request, my identity will remain anonymous.

I hereby consent and authorize, Tanya Fruge a Licensed Esthetician, and a SKIN SHEEK Certified Technician, to perform the procedure using "Clear" by Skin Sheek.

I acknowledge that the treatment goal is for esthetic improvement. I also recognize that independent results are dependent upon age, skin conditions, and lifestyle and that there is a possibility I may require further treatments of the areas treated to obtain the expected results at an additional cost.

I consent tot he taking of photographs to monitor treatment results.

I consent to before and after photographs of treatment being posted publicly.

I am not presently pregnant or lactating.

I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days.

I do not have a severe allergy to nickel.

I am not on blood thinners or high doses of aspirin.

I have been informed of the possible risks and complications which may include, but not limited to, infection, hyperpigmentation, redness, edema, and or bruising.

I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure.

I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken accurate in the past 6 months.

I have been given a copy of pre-care, post-care, and home instructions.

I understand home care and maintenance are required to achieve optimal results.

I understand numbing is optional and that post healing time is usually 7-10 days.

I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives.

Please list any Medical Diagnosis

Please list any Medications

Please list current Medical Treatments

On my own free will, I am requesting and providing my informed consent, to undergo treatment(s). I understand that this is an elective procedure, performed solely for cosmetic purposes and is not critical for my health. I assume all risks as my own. I hereby release Tanya Fruge from any liability, both seen and unforseen, now and forever.

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