Advanced Facial Consent

1112 Mt. Vernon Avenue, Marion, Ohio 43302

562 West Central Avenue, Delaware, Ohio 43015

Phone: 614-300-7988

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Current Medications & Supplements: Please list all current medications, over the counter medications, vitamins, herbal products and supplements. Certain medications may increase skin sensitivity, photosensitivity or risk of irritation.

While many topical products have minimal systemic absorption, the safety of certain ingredients during pregnancy or lactation has not been fully established. Additionally, hormonal changes during pregnancy or breastfeeding may increase skin sensitivity, risk of hyperpigmentation (including melasma), irritation, delayed healing or unpredictable treatment outcomes. For these reasons, elective cosmetic treatments such as dermaplaning,hydroplaning, chemical peels and red light therapy are often postponed during pregnancy, undergoing fertility treatments or while breastfeeding. If you are currently pregnant, trying to conceive or breastfeedling please seek clearance from your healthcare provider before receiving any treatments.

Neuromodulators (Botox, Juveau, Dysport, Xeomin, etc)Dermal Fillers (Juvederm, Restylane, RHA, etc.)Biostimulators (Sculptra, Radiesse, etc)Laser (IPL/non-ablative, Fractional, Fully Ablative)Dental Work, please describe: _____________________________________________________Recent Surgeries, please describe: ________________________________________________Vaccinations (past 3 months), please describe: ___________________________________

A minimum wait of (2) weeks is recommended after any injectable procedure such as neuromodulators, dermal fillers, biostimulators and others before receiving a chemical peel, dermaplaning, hydroplaning or aggressive exfoliation.

A minimum wait of (4) weeks is recommended after micorneedling or deeper dermal peels before receiving a chemical peel, dermaplaning or aggressive exfoliation.

Keloid formation (raised, thickened scars)Hypertrophic scarringDelayed wound healingPost-inflammatory hyperpigmentationAutoimmune skin disordersRecent skin trauma (cuts, burns, surgical incisions)Active acne lesions, open wounds, cold sores or infections

Certain aesthetic treatments including but not limited to facials, chemical peels, dermapalning, hydroplaning, microneedling, laser procedures, red light therapy and other exfoliating or resurfacing services-intentionally create controlled injury or stimulation to the skin. Individuals with a personal or family history of the above mentioned conditions may have an increased risk of excessive scarring, raised or thickened scars, hyperpigmentation or hypopigmentation, prolonged redness or inflammation, delayed healing or infection.

I understand that certain aesthetic treatments-including but not limited to facials, chemical peels, dermaplaning, hydroplaning, red light therapy, microneedling, laser procedures, and other exfoliating or resurfacing services-intentionally create controlled injury or stimulation to the skin. I further understand the risk involved (included but not limited to) if I or any family member have the above mentioned skin associated conditions.

Yes, I understand

Please disclose any additional information you believe is relevant to the treatment you will receive today. Please include any skin conditions and concerns, medical conditions, infections, open wounds, recent procedures, use of Accutane within the last 12 months and other topical retinoids such as Retin-A, Tretinoin and Adapalene. Certain medical conditions may require physician approval prior to treatment. Clients are responsible for informing the provider of any changes in medical history, medications or skin conditions before each appointment.

Glow and Luxury Facials: A non-invasive cosmetic skin treatment incorporating cleansing, exfoliation, masks, massage techniques and topical products intended to improve moisture balance, texture and overall appearance of the skin.

Chemical Peels: A controlled exfoliation procedure that uses professional grade chemical solutions to remove damaged outer layers of skin. This treatment promotes cellular turnover, improves skin tone and texture and stimulates collagen production.

Derma Planing: A non-invasive exfoliation procedure that uses a sterile, medical grade blade to gently remove dead skin and vellus hair (peach fuzz) from the surface of the skin. This treatment helps improve skin texture, promote cellular turnover and enhance product penetration.

Hyrdo Facials: A Hydro Facial is a multi-step, non-invasive skin rejuveation treatment that uses advanced vortex technology to cleanse, exfoliate, extract impurities and infuse the skin with hydrating and nourishing serums. This treament is designed to improved the overall skin health while addressing specific skin concerns.

Red Light Therapy: A non-invasive treatment that uses low-level wavelengths of red and near-infrared light to support cellular function and promote tissue repair. The light energy penetrates the skin to stimulate mitochondrial activity which may enhance collagen production, improve circulation and support the body's natural healing processes.

Side Effects: While facial treatments are generally well tolerated, potential risks may include, but limited to, temporary redness, flushing, irritation, dryness, swelling, peeling, sensitivity, itching or allergic reation to products used. These effects are typically mild and may vary by individual.

Post Treament Care and Client Responsibilties: Client agrees to follow all post-treatment instructions provided by staff. This may include sun protection, temporary avoidance of certain skincare products or treatments and monitoring for adverse reactions. Failure to follow post-care instructions may negatively impact results or increase the risk of irritation.

Unforeseen Risks and No Guarantee of Results:

I understand that aesthetic treatments including but not limited to facials, chemical peers, dermaplaning, hydroplaning, microneedling, red light therapy and the application of topical products or devices involve known and potential risks. While every precaution is taken to minimize complications, not all risks or side effects can be predicted.

Individual results vary based on skin type, condition, age, genetics, lifestyle and adhearance to recommended treatment plans. No guarantees or warranties, expressed or implied, have been made regarding the outcome of any cosmetic service.

Yes, I understand

The cost of skin treatments including but not limited to facials, chemical peels, dermaplaning, hydroplaning and red light therapy may involve several charges. This includes the professional fee for the treatment, follow-up visits to monitor the effectiveness of the treatment, any added treatments performed at the time of the originally booked service and the cost of any additonal materials used that are above the normal amount for the service being performed. It is unlikely that these treatments would be covered by your health insurance. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the treatment and will also be your responsibility. In signing the consent for procedure, you acknowledge that you have been informed about its risks and consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments.

Yes, I understand

I understand that photographs and/or video recordings may be taken before, during and after my treatment for the purposes of medical documentation in my confidential client record, treatment planning and progress comparison, quality assurance and provider education. I further consent to my photos and/or videos to be used in marketing and promotional materials including website, social media, print advertising or educational presentations.

I consent to ALL usage of my photographs and/or video materialsI consent to ONLY using my photographs and/or videos for the purpose of documentation in my confidential client recordI DO NOT consent to any photographs and/or videos for any purpose

Consent & Acknowledgment: By signing below, the client ackowledges that all information provided is accurate and complete, that all questions have been answered to their satisfaction and that the informed consent is voluntarily given for the cosmetic services described herein.

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Advanced Facial Treatment Consent

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