General Consent Form

Name

Date of Birth

ADDRESS

City, State & ZIP

PHONE

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial below:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure

I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treairflent/procedure has been explained to me, along with the risks and hazards involved.

Although it is impossible to list every potential risk and complication, i have been informed of possible benefite, riske, and complications.

I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.

I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost

I have read and understand all pre-treatment, post-treatment, and home care instructions. understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

I consent to 'before-and-after photographs for the purpose of documentation, potential advertising, and promotional purposes.

I understand that if f have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this Treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes Ml disclosure, and that it supersedes any previous verbal or wilder) disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.

Client Name

Client Name (Signature)

Date

Esthetician/Provider

Date

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GENERAL CONSENT FORM

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