I give consent and authorization to the esthetician from Heather Brown Face and Body Studio to perform the treatment we have discussed using Topical Benzocaine/Lidocaine/Tetracaine Cream and will hold him/her and his/her staff harmless from any liability that may result from this treatment.
I understand the esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any chemical peels, skin care procedures, laser treatments or infections that I have not disclosed to my esthetician. I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my esthetician. I have informed my esthetician if I am pregnant or lactating. I am over the age of eighteen (18) or have written consent to proceed as a minor. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.