Skincare Treatment Consent
Check each box below:
I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.
I understand that there are no guarantees as to the results of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience actual immediate results with this procedure, as each case is individual.
I understand that there is some degree of discomfort. (warming, tenderness, dryness, superficial flaking, etc.)
I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Shore Esthetics.
I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory.
I have revealed any medical conditions that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medication such as Accutane, hormone replacement therapy or use of Retin-A. Contraindicated medications should be discontinued seven days prior to the treatment with the exception of Accutane which must be discontinued for six months prior.
I have not had a peel and/or invasive treatment of any kind within 14 days of my treatment. I understand I cannot have another treatment until recommended by a licensed professional. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Shore Esthetics.
Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Serenity Skin Care of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.
I have read and fully understand the terms within the above consent. All of my questions have been addressed to my satisfaction. I understand English, or if I do not, I have appointed someone to translate this consent for in its entirety.
If client is under 18 years old, parental signature is required and identification will be needed at appointment. Please sign your name, select your relationship and type your full name below. A parent/guardian MUST be present for treatments of any minor.
Relationship to minor receiving treatment:
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm