Treatment and Consent
Please read and sign acknowledging you understand and agree to each statement:
-I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, and other treatment modalities (I.e Microdermabrasion, extractions, nano infusion, chemical peels, LED light therapy, microneedilng) as necessary or requested.
-I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.
-I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.
-I understand that there may be some degree of discomfort, i.e. stinging, prickling sensation, hotness or tightness.
-I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact my Service Provider.
-I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory.
-I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior.
-I have not had a peel treatment of any kind within 14 days of my treatment, from my Service Provider or any other Service Providers. I understand I cannot have another treatment until recommended by my Service Provider. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by my Service Provider.
-Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform my Service Provider of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.
-I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release Eccentric Glow Skin Therapy,LLC (Stephanie Lareau) against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.
-With my signature below, I give consent to receive treatments from Eccentric Beauty & Skin,LLC (Stephanie Lareau) and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider Eccentric Glow Skin Therapy (Stephanie Lareau). I further understand that neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that | have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider for any services rendered.