I agree to give permission to my skin care professional to perform any skin treatment that is consulted to me at Crystal Clear Skin and Beauty. (Hydrafacial, DiamondGlow, Dermaplaning, Chemical Peel, Oxygen Infusion, LED Light Therapy etc).
I agree to complete and be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, excessive alcohol will effect and diminish the effectiveness and result of the treatment.
I have disclosed to the service provider any surgical procedures, laser treatments, or facial procedures that I have had.
I am not presently pregnant or lactating. I have not had any recent chemotherapy or radiation treatments. I have not recently waxed on the area being treated today. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters or cold sores.
I will refrain from excessive sun exposure and the use of a tanning bed while I am undergoing treatment. I have disclosed to my skin care professional any treatments of any kind that I have received within 14 days.
I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. I understand that the following conditions preclude me from having this treatment at this time and verify that none of these conditions apply to me at this time.
History of being “highly allergic” to anything, pregnant or lactating, current use of antibiotics (topical or systemic), use of Accutane® within the past 12-months, laser resurfacing surgery within the last 12-weeks, use of Retin-A®, Renova®, retinoids in the last 4-weeks. Using glycolic acid products, broken skin on areas to be treated, visible inflammation or inflammatory lesions, recent peels within four weeks, herpes virus (cold sores) on mouth, currently undergoing chemotherapy or radiation treatments, laser hair removal within 6 weeks.
I understand the cost of the treatment and the fee structure has been explained to me. My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, or pigmentation levels.
I consent to the taking of photographs to monitor treatment effect and results if desired by my skin care professional. In the event of any questions or concerns, I will consult my service provider immediately. I understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the skin care professional and staff harmless from any liability that may result from this treatment. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
