Client Informed Consent for Advanced Treatment


Skin Type: Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your esthetician determine the most appropriate way to approach your treatment(s):

Are you of Asian heritage, Type V or VI, and/or have a history of keloid scarring?

Please indicate the type of advanced esthetic service(s) below to which you consent. Checking the box next to a treatment indicates you provide your consent for treatment. Prior to receiving a service, be sure to review the online treatment description as it includes information with any pre/post care details. You will receive a hardcopy of post care instructions at the time of your service. Please consult the esthetician if you have any questions regarding the nature of these advanced services:

I elect to receive the esthetics procedure(s) indicated above and provide my full consent. I declare that I am over the age of 18, not under the influence of drugs or alcohol, not pregnant or nursing, not on blood thinners or blood pressure medication, and am not an insulin dependent Diabetic.

I understand if I am under the age of 18, Parental Consent is required for me to obtain the procedure(s). Under no circumstances may I have these services if I am under the age of 14. I represent that the stated date of birth is truthful on this form.

I understand that many medications and some diseases and disorders may either contraindicate me for treatment or affect the results. I understand I should continue taking my medications, and disclose all prescription and non-prescription drugs, supplements, topically applied products, eye drops, etc. that I use or take to the esthetician.

I understand that due to the nature of this treatment, results cannot be predicted, and I acknowledge that no guarantees of the results can or have been made and that there is a possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.

Warning: Treatment is not available to clients who are on Accutane. Clients using anticoagulants must disclose this to the esthetician, as treatment may need to be modified to mitigate additional risk associated with the use of these drugs. Clients with a pacemaker, internal defibrillator, or metal implants must disclose this information as this may contraindicate them for treatment.

For women of childbearing age: You confirm that you are not pregnant and do not intend to become pregnant during the course of treatment.

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, medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. I have discussed, read, or been given a copy of, or digital access to the pre-treatment and post-treatment instructions. I understand the importance of following all instructions given to me. Should I have additional questions or concerns regarding my treatment or post-treatment care, I will consult with the esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

Pre-and-Post Procedure Instructions: I have received, and will strictly adhere to, all pre-and-post procedure instructions. I understand that for those with more color in the skin it may be advised to use a lightening agent leading up to the procedure to suppress melanin in the skin.

I understand for some services there may be an extended period of recovery following the procedure(s), and that following post-treatment protocol is crucial for healing, scar prevention, hyper-pigmentation and hypo-pigmentation. I understand that avoiding sun exposure after the procedure is crucial to reduce the risk of color change and will apply a minimum of SPF 30 as is recommended.

I understand that initially, depending on the treatment performed, it is possible that the skin treated may be red and swollen, that fine, thin scabs may form, and that the healing process may typically take up to three weeks. I am aware that in rare cases healing could take as long as three to six months.

I understand the importance of following all pre-and-post treatment instructions given to me. I have discussed, read, and understand the pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. I understand that these resources are available on the website in the pre/post section and that I can request a hardcopy of these pre and post-treatment care instructions at the time of my service. In the event that I have additional questions or concerns regarding my treatment or post care instructions, I will consult the esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

General Risks of Procedure(s): I understand there are possible risks associated with my procedure, including, but not limited to: minor burns, blistering, hypopigmentation (lightening of the area), hyperpigmentation (darkening of the area), redness, swelling, allergic reactions, bruising, scarring, pin-point bleeding, pimple-like bumps, dry skin, tingling, and other similar side effects and/or reactions. I understand these risks also include, but are not limited to, the following:

Scarring: The treatment can create bruising and a moderate burn or blister to the skin. Depending on treatment received, more serious side effects may include, skin indentations or subcutaneous fat loss, and open sores that lead to infection.

Pigmentation: The treated area may become either lighter (hypo-pigmented) or darker (hyper-pigmented) in color. This is rare and is usually just temporary, however may become permanent.

Infection: Although infection following the treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes Simplex virus infections around the mouth can occur post-treatment, even if there is no past history of Herpes Simplex virus infections in the mouth area. Clients with a history of HSV in the treated area are encouraged to seek preventative therapy. Should any type of skin infection occur, additional treatment, including antibiotics, may be necessary.

Skin tissue pathology: Only clearly benign pigmented lesions can be treated. A doctor’s clearance should be obtained in the case of this type of treatment. Treatment directed at abnormal lesions can cause malignant cells to develop and laboratory examination of the tissue specimen may not be possible.

Allergic reactions: Due to skin surface disruption, irritation and histamine reactions may occur resulting in itching, dermatitis, or other forms of sensitivity. In rare cases, local allergies to topical preparations have been reported.

I give the esthetician permission to perform the selected treatment(s)/procedure(s) we have discussed and will hold her harmless and nameless from any liability that may result from the advanced treatment(s)/procedure(s). I understand that pre-and-post treatment information will be discussed and hardcopies will be provided at the time of the serviced, or I may print/review an e-version of the treatment information on I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I agree that this constitutes full disclosure, and it supersedes any previous verbal or written 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(s) and accept the risks. 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 procedure that may be affected by the treatment performed today.

Esthetician Signature: (To be Signed at the time of appointment) ________________________________
Date: (To be dated at the time of appointment) ________________________________