The Skin Classic Machine ONLY Consent Form
The undersigned acknowledge that Crystal Ngozi Beauty and Esthetics has explained the nature of the Skin Classic treatment procedure including the risks and dangers inherent such as but not limited to: infection, hyper or hypo pigmentation, redness, edema, or bruising. As in any cosmetic procedure, the treatment goal is for esthetic improvement, not perfection. The number of treatments necessary will vary between individuals and the areas being treated. Factors including skin color, age, hormonal activity, inherited conditions, and other influences may decrease effectiveness of treatments. I desire and consent to the use of Skin Classic treatments on me and in consideration of receiving those treatments, I hereby release and forever discharge Crystal Ngozi Beauty and Esthetics from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures. I give this release on behalf of myself and my current and future heirs, executors, administrators, assigns and any other person or entity making a claim on my behalf. No refunds on treatments.
Full Name
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What is your preferred pronoun?
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She / Her / Hers
He / Him / His
They / Them / Theirs
Other
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Phone Number
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Email
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How did you hear about us?
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Referral
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Other
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I agree that I do not have any of the following contraindications as failure to disclose this information may result in permanent injury: any dermatological disorders in the treatment area; pregnancy; Accutane use within 12 months of treatment; moles; anything considered suspicious by a dermatologist or any physician; pacemakers; lupus; melasma; any irregularity with a blood supply; bleeding disorders
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I understand that there may be some degree of minor discomfort (redness, swelling or bruising).
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I understand that to achieve maximum results, I may need several treatments and will need to use daily products to heal and protect my skin
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I understand that the possibility of irritation and redness exists and that I should notify my skin care professional if irritation persists
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I will follow all prescribed directions regarding post treatment care.
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I agree to all conditions and agree to have this treatment performed on me
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I have been given the opportunity to address all of my questions and concerns about the risks, hazards, and aftercare for the procedure(s) that will be performed with my consent.
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I confirm that the information I have provided is accurate and complete. I understand that withholding relevant information may affect my treatment results, and I will not hold my Esthetician responsible for any adverse reactions. I consent to Crystal Ngozi Beauty & Esthetics using my skin photos to track my progress and for internal research and service development. All images will be kept anonymous and will never be used for marketing without separate permission.
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I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
Please upload photos of the skin irregularity you wish to remove.
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Please upload photos of the skin irregularity you wish to remove.
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Please upload photos of the skin irregularity you wish to remove.
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