Zemits Facial Treatment Consent Form
Please review each section carefully and provide your initials and signature to confirm your understanding and consent for the Zemits Facial Treatment.
Patient Name
*
I have read the Zemits Facial Treatment Information and Instructions and have had an opportunity to ask questions about the procedures and treatment. (Patient Initials)
*
Contraindications
Pacemaker or metal implants (contraindication for RF, Microcurrent)
Recent accident or serious injury
Recent surgical or dental procedure
Rosacea, telangiectasia/couperose (contraindication for vacuum aspiration)
Retin-A, Retinol (contraindication for skin exfoliation)
Stage III or IV acne (contraindication for dermabrasion)
Skin-lightening or bleaching agent
Sunburn
Swollen or infected tonsils
Thyroid conditions (contraindication for RF, Ultrasound, Microcurrent)
Type I diabetic (contraindication for RF, Ultrasound, Microcurrent)
Under medical care for an existing or suspected condition or disease
Viral infection, influenza
Pregnancy and breastfeeding (contraindication for RF, Ultrasound, Microcurrent)
Patient Initials (Contraindications Acknowledgment)
*
What to Expect
After Zemits Facial Treatment, your skin may experience temporary irritation, redness, or tightness. These reactions are normal and typically resolve within 48-72 hours depending on skin sensitivity. Sensations such as tingling and stinging in the treatment area may occur within a few hours. Client experiences vary; some may have delayed symptoms. Most clients see immediate results with smoother, hydrated skin for several weeks with proper home care.
Patient Initials (What to Expect Acknowledgment)
*
Aftercare Instructions
After Zemits Facial Treatment, protect your skin from sunburn and sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.
Patient Initials (Aftercare Instructions Acknowledgment)
*
Patient Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: