SECTION 2: CLIENT CONSENT FORM
(Initial each acknowledgement line below)
1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months.
_____(initial here)
2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use
medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two
days after any aggressive facial exfoliation treatment.___(initial here)
3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. The appearance of
pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home
regimen. _____(initial here)
4. I acknowledge that my skin might experience temporary irritation, tightness, or redness which usually dissipates within
72 hours depending on skin sensitivity. _____(initial here)
5. I have disclosed my history of allergies above. _____(initial here)
6. I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience allergic
reactions._____(initial here)
7. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible
to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure, especially between 10am - 2pm.
_____(initial here)
8. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been
expressed or implied. _____(initial here)
9. I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of
the recommended take-home regimen for 2-4 weeks following the treatment. _____(initial here)
10. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician and/or
skincare practitioner during and following the treatment. _____(initial here)
11. I acknowledge that I am not pregnant/lactating. _____(initial here)
12. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. _____(initial
here)
13. I acknowledge that I have answered all questions truthfully and completely. _____(initial here)
14. I release Edge Systems, the ______________ (Aesthetician/Doctor), management and staff of _______________
(Clinic/Ofce) from any and all liability associated with any injuries and/or current or future conditions resulting from the
skincare procedures or products._____(initial here)
15. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising
purposes. My name will not be used to identify these photographs without my written approval. _____(initial here)
By signing below, I certify that I have read and fully understood the contents of this consent form, and that the
information I provided above are complete, accurate, and up-to-date to my knowledge.
CLIENT SIGNATURE: DATE:
OPERATOR SIGNATURE: DATE:
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