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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: March 5, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's 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*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's 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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's 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.


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