I hereby request and authorize my Esthetician with Wild Heart Aesthetics, to perform the following treatment/procedure for me:
I am fully aware that my condition is of cosmetic concern, and that the decision to proceed is based solely on my expressed desire to do so. I understand with any treatment/procedure there is a possibility of short term effects, as well as rare side effects, and all of the effects pertaining to this treatment/procedure have been fully explained to me.
I confirm that I am not pregnant or breastfeeding at this time, and that I have not taken isotretinoin (also known as Accutane) within the last three months. I have also completed a medical history checklist, and have been informed about what I "must do" and "not do" before, during, and after the treatment/procedure.
I understand that there is no guarantee of results with any treatment/procedure, and that there is always some risk involved, albeit small. Clinical results may vary depending on individual factors, including age, medical history, amount of sun damage, textural problems, skin type, client compliance with pre/post treatment instructions, and medications taken. I understand that it is possible that more than one treatment may be necessary to achieve the desired effects, and the fee structure has been fully explained to me.
If provided with pre and/or post treatment instructions, I will adhere to the given regimen. I certify that I have been fully informed of the nature and purpose of the treatment/procedure, expected outcomes, and possible complications. I understand that no guarantee can be given as to the final result obtained. If I was given a pre-treatment protocol, I assert I have followed the plan carefully and fully.
The Esthetician/Technician has explained the nature of my condition, the nature of the treatment/procedure, and the benefits to be reasonably expected compared with alternative approaches, including the likely results of not performing the treatment/procedure. The Esthetician/Technician has discussed the likelihood of any risks and complications of this treatment/procedure. The Esthetician/Technician has also indicated that with any procedure there is always the possibility of an unexpected complication.
The information I have provided regarding my medical history is accurate to the best of my knowledge, and I affirm I do not have any ailments or conditions that would make this treatment/procedure incompatible with my health and well being.
By signing this form, I certify that I have read and fully understand the contents of this consent form, and I have been sufficiently informed of the benefits and risks involved with treatment; that I am at least 18 years of age, and fully competent to give my consent. I acknowledge I have been given the opportunity to ask any questions I may have, and those questions have been answered. I duly authorize the Esthetician/Technician to perform the above specified treatment for me, as well as any post treatment requirements that may be necessary. I understand my Esthetician/Technician will take every precaution to minimize or eliminate negative reactions as much as possible, and I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. I agree to hold my Esthetician/Technician and Wild Heart Aesthetics, not liable for any damages, injuries, or claims that may result from this treatment/procedure.