Glo2Facial Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Precautions

• There may be some degree of minor discomfort during the treatment.

• You may experience redness and irritation. Please notify me if it does happen prior to attempting any home remedies.

• Avoid sun/tanning booths and extreme weather conditions for 1 week before and after treatment.

• No waxing, depilatory creams, or methods of hair removal to the treated area for at least 5 days prior. No IPL/laser hair removal 14 days prior.

• Avoid neurotoxin (Botox) and injectable fillers, microneedling to the treated area at least 2 weeks prior.

• Discontinue products containing any exfoliating agents and active ingredients such as retinol 3 days before treatment.

• For a client with facial outbreaks such as herpes simplex virus. Medication must be taken per physician’s instructions.

After your Glo2Facial

• Keep skin clean, moisturized and sun protected.

• Use a mild cleanser before bedtime for 3 days after treatment.

• Avoid glycolic, alpha hydroxy, beta hydroxy, retinol, benzyl peroxide and topical acne medications for 3 days after treatment.

• Resume prescription retinoid products 3 - 7 days after treatment.

• Avoid harsh chemicals, rubbing, and tanning for 1 week after treatment.

• Avoid scratching or picking at the skin.

• Reapply SPF every 2 hours when in direct sunlight for at least 2 weeks after treatment.

By signing this form, you acknowledge you have been made aware of the potential risks that accompany a Glo2Facial and consent to treatment with understanding of the below:

• I understand there may be some degree of minor discomfort during the treatment.

• I understand that the possibility of redness and irritation exists and agree to notify my provider if it does prior to attempting any home remedies.

• I understand that there are no guarantees with any aesthetic procedure.

• I understand that to achieve the best results, it is ideal to receive consistent maintenance treatments on a monthly basis.

• I will follow the pre and post care instructions given to me by my provider.

• I agree to release my photos and videos for marketing purposes, including social media, website, and promotional materials. I understand my identity will be protected upon request.

I agree to release my photos for marketing purposes under the following circumstances:

Initial*   I have given an accurate account of any OTC or prescription medications that I use regularly, and I am not presently using isotretinoin (Accutane).

Initial*   I have not had any recent facial surgical procedures, injections, chemical peels, or skin treatments that I have not disclosed to my therapist.

Initial*   I am not ingesting or using topically any other OTC product or prescription medication/agent that has not been disclosed to my therapist.

Initial*   I am not presently pregnant or lactating and I am over the age of eighteen (18).

Initial*   I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin.

Initial*   I have not recently waxed or used a depilatory (such as Nair) on the area to be treated.

Initial*   I do not have a history of keloidal scarring, excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, or any other existing condition that may interfere with the positive outcome of this treatment.

Initial*   I agree that I am willing to follow recommendations by my esthetician for home care.

Initial*   I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions.

Initial*   In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my provider immediately.

I,   First Name*   Last Name* , give permission to my provider, Angela Branch Skin Care, to perform the Glo2Facial we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I understand he/she will take every precaution to minimize or eliminate potential negative reactions. I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.

Client Signature

Date

Glo2Facial Consent Form

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