Micro Current Consent Form | Naked Face Spa LLC

Microcurrent Informed Consent

Treatment, please be aware of the following information and possible risks. Please initial:

I understand there are certain contraindications that would preclude me from receiving microcurrent treatments, including autoimmune disorders, diabetes, embolism, epilepsy, melanoma, metal implants including plates/pins/screws, open wounds, pacemaker use, phlebitis. pregnancy, thrombosis, and varicose veins.

I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment.

I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk.

I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.

I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure.

I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

I understand that it is imperative to my health that 1 disclose all of the information requested in the Client Profile/Health History.

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

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

I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the microcurrent procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that 1 have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but riot disclosed at the time of this procedure, which may be affected by the treatment performed today.

Client Name

Client Name (Signature)

Date

Skin care specialist

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Microcurrent Informed Consent

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