TREATMENT + CONSENT
1. I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, extractions, and other treatment modalities (e.g. Microcurrent, High frequency, Ultrasonic, LED Light Therapy, Nano Infusion, and other treatment modalities as necessary).
2. 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 homecare.
3. 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 individual's results may vary.
4. I understand that there may be some degree of discomfort (stinging, prickling sensations, hotness, or tightness) during treatment.
5. 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.
6. I understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and facials are not a replacement for medical treatments.
7. I have voluntarily elected to undergo treatments at The Light Esthetics and the purpose of the treatment has been explained to me, along with the risks and hazards involved.
8. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
9. I acknowledge that this therapy and the treatments involved have no sexual intent and touching the therapist is strictly prohibited.
10. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I have additional questions or concerns regarding my treatments or suggested homecare products/ post-treatment care, I will consult the service provider immediately.
11. 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 sunblock protection with a minimum SPF-30 is mandatory.
12. I will reveal any medical conditions that may affect 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.
13. I have not had a peel treatment or any advanced treatment within 14 days. I understand I cannot have another treatment until recommended by a licensed professional at The Light Esthetics Studio LLC. I understand my responsibility of properly fulfilling the appropriate aftercare instructions as explained by the staff.
14. 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 the Light Esthetics Studio LLC of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.
15. 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 The Light Esthetics LLC and any of its employees 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.
16. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
17. I understand that my data will be held in strict confidentiality. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications do happen, the clinic will not be held liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
18. By my electronic signature below, I give consent to receive treatments at The Light Esthetics Studio LLC and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I 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 or The Light Esthetics Studio LLC for any services rendered.