I hereby confirm that I am of legal age over 12 years old and that I am not under the influence of drugs or alcohol. I also affirm that I am not presently pregnant or nursing. I willingly provide my consent for the facial treatment that has been discussed and specified.
I have voluntarily elected to undergo this facial treatment after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved.
I attest that I have read the preceding paragraphs, initialed them, and understood the consent and procedure allows. I fully acknowledge that I made the decision to get this facial treatment done.
My signature acknowledges that I have read and agree that I will adhere to all of the aforementioned statements that I have initialed.
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results that independent results are dependent upon age, skin condition, and lifestyle, and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. If I will have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently using. I have read and fully understand this agreement and all the information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.