INFORMED CLIENT CONSENT FORM

INFORMED CLIENT CONSENT FORM
FIRST & LAST NAME
DATE of BIRTH

MonthDayYear
Date
Address

ADDRESS

Street Address Line 2

CITYState / Province

ZIP
PHONE
EMAIL
example@example.com
Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.
I hereby consent to and authorize the esthetician to perform the following treatment/procedure: Facial / Chemical Peel / Enzyme Peel / Radio Frequency / Microcurrent / LED Light Therapy / Facial or Body Waxing / Brow Stain
I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved.Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Health History Form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken orally or topically including any past reactions to products and medications used.I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.I have read and understand all pre-treatment, post-treatment, and home care instructions. understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
I understand that if I have any concerns, I will address these with my technician/esthetician. If at anytime I am uncomfortable, I can stop service. I also acknowledge If the esthetician is uncomfortable, the service will be stopped. I give permission to my esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.
Client Name (Printed)
Client Name Signature
Date

MonthDayYear
Date
Should be Empty:

INFORMED CLIENT CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.