I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of
this treatment has been explained to me.
I understand and acknowledge that there are risks involved with the treatment I will be
receiving. Although it is impossible to list every potential risk and complication, I have been
informed of possible benefits, risks, and complications, and I have had the opportunity to ask
questions regarding these risks and other possible complications
I also recognize there are no guaranteed results and that independent results are dependent
upon age, skin condition, and lifestyle and that there is a possibility I may require further
treatments of the treated areas to obtain the expected results at an additional cost.
I have read and understand the post-treatment home care instructions. I understand how
important it is to follow all instructions given to me for post-treatment care. In the event that I
may have additional questions or concerns regarding my treatment of suggested home
product/post-treatment care, I will consult the esthetician immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history,
including all known allergies or prescription drugs or products I am currently ingesting or using
topically.
I have read and fully understand this agreement and all information detailed above. I
understand the procedure and accept the risks. I agree I will assume the risk and full
responsibility for any and all injuries, losses, side effects, or damages which might occur to me
while I am undergoing this procedure. I do not hold the esthetician, whose signature appears
below, responsible for any of my conditions that were present, but not disclosed at the time of
this skin care procedure, which may be affected by the treatment performed today.
