Consent - Diamond Glow

Simply Skin Las Vegas

Client Care Treatment Instructions - Diamond Glow
Name*

First NameLast Name
PRE-TREATMENT INSTRUCTIONS
- You MUST cease all waxing, laser and electrolysis for 2 weeks prior to treatment
- You cannot use Retinoids or any other exfoliating products for 7 days prior to treatment
- You may be asked to stop any topical medications or skin care products prior to treatment
- The use of self-tanning products/bronzers must be discontinued one week before treatment. Any residual self-tanner must be removed prior to treatment
- You MUST remove contact lenses prior to the procedure (if applicable)
- If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended to prevent a breakout. Follow the directions for your particular antiviral medication
- The treatment area should be clean of any perfume, makeup, lotions, sun block, or any other chemical or skincare products
INTRA-TREATMENT CARE
- At the beginning of every treatment session, we will review your medical status, and ask if there have been any changes. Please remember to inform us of any changes such as health, medications, and sun exposure. Changes may alter the effectiveness of treatment and may cause side effects and/or complications
- The skin is cleaned prior to treatment
- Topical serums, moisturizers, or SPF may be applied following your service
- Safety considerations are important during the procedure
- During the treatment you may experience a scratchy, stinging sensation. This sensation should subside during the post-treatment protocol shortly after the treatment is finished.
POST-TREATMENT INSTRUCTIONS
- Immediately after the treatment, there may be redness in the areas that are treated. The redness should subside post-treatment. It is normal that the treated area, may feel scratchy, or have a stinging sensation post treatment. You may experience temporary tightness, or slight swelling, that should dissipate in a few hours post treatment
- No exfoliating 3 days post treatment, as your skin has just received an exfoliation
- You could experience a breakout post DiamondGlow service as the skin purges from impurities. This will resolve on its own.
- Makeup may be used after the treatment, unless there is skin irritation or breakage. It is recommended to use new makeup to reduce the possibility of contamination. Make sure that you have moisturizer on under your makeup.
- Please make sure the moisturizer used does not have alpha-hydroxy acids, retinols, benzoyl peroxide or astringents
- Use sunscreen SPF 40 or higher at all times throughout the treatment and for 1-2 months following
- If you fail to use sunscreen, you may be susceptible to sunburn and hyperpigmentation
- Avoid picking or scratching the treated skin. During your treatments, DO NOT exercise any other facial, skin rejuvenation, CO2, IPL, Laser, or any other methods or products on the treated area for 2 weeks.
- DO NOT exercise any other hair removal methods or products on the treated area NO waxing, NO threading/stringing, NO sugaring, NO plucking/tweezing, NO depilatory creams (nair, veet, etc.) for 2 weeks.
- There are no restrictions on bathing except to treat the skin gently for the first 48 hours, and to use cool water. Skin should be patted dry and NOT rubbed.
- Please do not hesitate to call or text us at (702) 823-0852 if you have any questions or concerns
ACKNOWLEDGMENT: I acknowledge that I have had the opportunity to review the Client Care treatment Instructions prior to treatment.*

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Client Consent, Rights, Responsibilities
We are committed to serving you with compassion, care, skill, and respect. As one of our clients, you have choices, rights, and responsibilities.
Client's Name*

First NameLast Name
I hereby authorize Simply Skin Las Vegas, its employees/agents/clinicians to perform the DiamondGlow treatments on me. Treatment sites include face, forehead, sideburns, lip, chin, and neck

DiamondGlow is a next-level skin resurfacing technology that simultaneously exfoliates and extracts, while infusing skin with targeted serums to address specific skin quality concerns. The DiamondGlow device is a general dermabrasion device that gently exfoliates and removes the top layer of skin, and delivers topical cosmetic serums into the skin.

I understand that the treatment is purely elective, and I hereby consent to be a patient receiving treatment. I understand that certain complications are rare, but possible.

Other potential risks include itching, blistering, burns, infection, scabbing, and failure to achieve desired result.
The procedure may result in the following side effects or adverse experiences, and may carry some risks
- DISCOMFORT – Some discomfort may be experienced during treatment
- REDNESS/SWELLING/BRUISING – Short-Term/temporary redness (erythema), swelling (edema), and/or mild sunburn-like effects of the treated area is common and may occur. There also may be slight bruising.
- I acknowledge that facial telangiectasia (small blood vessels) is sometimes more apparent immediately after the treatment, when the skin is thin, and will diminish after my skin has recovered from the treatment
- SKIN COLOR CHANGES – There is a possibility that the treated area may become either darker (hyper-pigmentation) or lighter (hypo-pigmentation). These conditions usually resolve within 3-6 months, but permanent color change is a rare risk. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of color change.
- SCRATCHES – Treatment can result in scratches, petechiae, and in the rarest of occasions, pinpoint bleeding of the treated areas. If any of these occur, please contact our office immediately.
- INFECTION/BREAKOUTS – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection such as pain, heat, or surrounding redness develop, please call our office immediately. If you have had a history of perioral or genital herpes simplex virus, antiviral therapy is recommended in order to prevent a breakout. Follow the directions for your particular antiviral medication.  
- SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff. Compliance with the aftercare guidelines and avoiding sun exposure before and after the treatment reduces the risk of scarring.
- ALLERGIC REACTIONS – In rare cases, local allergies have been reported. If you have a nickel allergy please advise staff.
I am aware of the possible complications/risks involved with the procedure and subsequent healing period. *

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I fully understand that it is impossible to make guarantees regarding the outcome of any cosmetic/medical treatment and/or procedure. I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post- treatment instructions, and individual response to treatment. I acknowledge that no guarantees, either expressed or implied have been made to me regarding the outcome of any treatments and/or procedures.*

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I understand that I am financially responsible for all amounts due for services rendered at the time of the treatment. I also authorize the release of information to a licensed physician of the facility’s choosing for the purposes of professional interpretation and establishment of treatment recommendations.*

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I understand that my procedure may involve a series of treatments*

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I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.*

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I HAVE THE RIGHT TO:
- Be treated with dignity and respect
- Know the name(s) and professional status of the person(s) serving you
- Privacy
- Confidentiality of your records
- Receive accurate information about your health-related concerns
- Know the effectiveness, possible side effects and problems of all forms of treatments
- Participate in choosing a form of treatment
- Receive education and counseling
- Consent to, or refuse any care or treatment
- Review your medical record with your clinician
- Amend your medical records
- Receive any information about services
I ALSO HAVE THE RESPONSIBILITY TO:
- Seek medical attention promptly
- Be honest about your medical history
- Ask about anything you do not understand
- Follow health advice and instructions
- Report any changes in health or medication
- Respect our policies
- Seek care during normal business hours and to provide useful feedback regarding our services and policies
If applicable, at the time of treatment, I can neither be pregnant nor nursing if using the Pore Clarifying Serum and have advised staff if I am pregnant *

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I have provided my past and current medical history and medications and have informed the staff of potential allergies to nickel*

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I consent to the taking of photographs during the course of my DiamondGlow for healthcare records – we must be able to document any reactions, pre-existing marks in the area, etc. These will be unidentifiable and will remain with your medical records*

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I consent to using my photographs for medical education and/or marketing purposes

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ACKNOWLEDGMENT: I understand the information given to me and the risks that have been outlined. I will be given the opportunity to ask questions about the procedure during my consultation and will not proceed with treatment until my questions regarding the procedure and the risks associated have been answered satisfactorily. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so with a complete understanding of the risks. *

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Client Signature
If minor, Parent/Legal Guardian Signature

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Simply Skin Las Vegas

Simply Skin Las Vegas