Loading...

DIAMONDGLOW SKIN TREATMENT CONSENT FORM

 

Please read carefully before you sign the waiver and consent to receive DiamondGlow-DermaInfusion facial treamtent at Ease Medspa & Wellness Group.

DiamondGlow™-Dermalinfusion is an advanced skin-resurfacing treatment that simultaneously Exfoliates, Extracts, and Infuses Skin with condition-specific serums to improve skin health, function and appearance.

  • I acknowledge that I might experience a scratchy, stinging sensation during the treatment. This sensation will subside during the post-treatment protocol. 
  • I understand that if I fail to use sunscreen, I am more susceptible to sunburn and hyperpigmentation. 
  • I acknowledge that I have not been on medication for acne therapy during the past six months.
  • I acknowledge that I have not been using retinoids for the past 3 days and I will discontinue the use of retinoids for 1-3 days after therapy.
  • I acknowledge that facial telangiectasia (small blood vessels) is sometimes more apparent immediately after the treatment when the skin is thin and will diminish after re-epithelialization (build up of dead cells).
  • I acknowledge that any area around the mouth or face that is prone to cold sores will be avoided during the treatment, and that I should avoid all treatments during an outbreak. 
  • I acknowledge that my skin may experience temporary tightness, mild erythema (redness), or slight swelling, which should dissipate in a few hours.


 

I agree to remove my contact lenses prior to the procedure (if applicable). 


 

I understand that my physician and/or the operator uses tools that are either disinfected or disposable. 


 

I understand if I am pregnant, lactating, have rosacea, salicylate/aspirin sensitivity, or an outbreak of any skin condition, I should consult with my physician prior to receiving the DiamondGlow-Dermalinfusion treatment.


 

I hereby agree to have the DiamondGlow-Dermalinfusion treatment performed on my skin by a trained operator and to follow all post-treatment protocols.


 

Dated: July 1, 2025

First Client's Name
First Name*
Last Name*
Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!