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Microcurrent Consent Form
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Name
*
First
Last
Email
*
Any Facial Add On’s?
*
Hydrofacial Signature
MIcrodermabrasion
Hydro Deluxe
Hydro Platinum
N/A
If said yes to Hydro Signature/ Deluxe or Microdrmabrasion:
I release any liability for any miscommunication I could have with my aesthetician about my at home, skin care, or current skin conditions or disorders. Hydrofacial may result in redness, or very slight hickey. Bruising, I release any liability that I would project on polishbyjess LLC.
I agree that micro dermabrasion is a diamond metal tip mechanical facial device used for exfoliation, and may result in scratching and mention to any information needed to the aesthetician for my at home skin care or other products I may use that will result in a dryer skin environment, presenting me with scratches on my face and not hold polishbyjess LLC liable
Platinum? If Yes please agree to our terms and conditions.
*
I agree that the hydrofacial platinum is a nano needling, Hydro facial and manicure combination. This is a long service and I will take the patients that it needs for said service to get done.
I agree that certain depths of micro needling are not legally allowed under the DBPR & Board of cosmetology in the state of Florida. I consent to have nano needling done, and nothing further beyond out of the scope of practice for aesthetician, and will not sue or report. I agree that I will not demand deeper deaths or any multiple passes over what my aesthetician has already gone over due to the strict rules of what DBPR and board of cosmetology gives aestheticians in the state of Florida as their scope of practice. I trust, and will put my confidence in my aesthetician, and not question her technique, professionalism, or ability to perform said service.
I agree I will not hold polish by Jess liable for any of the nano needling or failure to follow any aftercare.
N/A
Added Nails to your service?
Yes
No
N/A
Please include a photo of current nail state:
Click or drag a file to this area to upload.
If you have polish or any system off please soak off and not tear off system, having a system on will not give me a clear look of what we’re working with, for legal and insurance purposes I will NOT work on extremely damaged nails/ any infections/ I also legally do not work over any nail techs product or system that isnt mine or take off anyone else’s work.
Per Nail Add On’s (Per Nail)
French Manicure - $ 3.00
Nail Design - $ 3.00
Hand Painted Art - $ 25.00
3D Acrylic Art - $ 15.00
Hot Stones - $ 15.00
Adding lashes?
*
Yes
No
N/A
If you chose Yes
*
I agree that lash extensions are and can be tricky with professional glue and reactions can happen. I release all liability from polishbyjess LLC
I understand if I’ve had a reaction to eyelashes in the past I will mention to aesthetician before treatment
I understand the severity of washing my eyelash extensions due to the possible chance of going blind, and will do my diligence of washing them
Lets get started with Microcurrent!
Health History, Please select of any apply to you:
*
Are you pregnant or nursing?
Do you wear contacts or glasses?
Do you have metal piercings?
Do you use a pacemaker?
Do you have any heart problems?
Do you have high/low blood pressure?
Have you been sick in the last week or two?
Have you had recent facial treatments in the past month?
Do you use Retin-A, Accutane, or any other prescribed topical vitamin A derivative?
Have you had recent Botox, Juvederm or any other injectables or threading?
Do you have metal implants, tooth fillings or any other metal/copper dental implements?
Do you have an autoimmune disorder or connective tissue disease?
Conditions current or recent in the past year:
*
Acne rosacea
Light sensitivity
Sensitive skin
Bells palsy
Melanoma
Skin inflammation
Thyroid condition
Cold sores
Diabetes
Epilepsy
Stroke
Varicose veins
Migraines
Sensitive skin
Hormonal issues
Allergies
Other
N/A
If other that you think will contradict or feel safe mentioning:
Comment or Message
Although every precaution will be taken to ensure your safety and well-being before during, and after treatment, please be aware of the following information and possible risk, please check the boxes below
*
I understand there are certain contradictions that would preclude me from receiving the microcurrent treatments, including autoimmune disorders, diabetes, epilepsy, melanoma, metal implants pins, plates, screws, open wounds, pacemaker, pregnancy, thyroid, or varicose veins
I understand that the use of Botox, Juvéderm and other injectables may be disclosed prior to treatment
I understand that my current treatment involves conducting mild electrical currents through the body that can inherit some type of risk
I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions, including redness, and other irritation
I understand that some clients reports slight tingling flashing of the optic nerve sensations or a metallic taste in the mouth during procedure
I understand that while the goal of this treatment is improve the skin, but does not guarantee results can be made immediately
I understand that it’s imperative to my health data disclose all information requested in the client profile and health history
I have cited all conditions and circumstances regarding my health medication‘s taken and any past reactions or current conditions
I understand that additional conditions can occur to be discovered during procedure, which could affect my ability to tolerate the procedure
I understand that if I have concerns, I will address them with my aesthetician. I give permission to my skin care specialist to perform the microcurrent procedure. We have discussed and release polishbyjess from any liability that may result from this treatment.
I certified I have read fully and understood all of the paragraphs and information in this form I do not hold the skin care specialist aesthetician polishbyjess, LLC, whose signature appears below with mine responsible of any conditions that were present
Signature
Clear Signature
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