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Skin Sheek Client Consent Form

I hereby consent and authorize, Lisa Primps a Licensed Esthetician, and
a SKIN SHEEKTM Certified Technician, to perform the following procedure using “Clear” by Skin SheekTM.

I acknowledge that the treatment goal is for esthetic improvement, I also recognize
that independent results are dependent upon age, skin conditions, and lifestyle
and that there is a possibility I may require further treatments of the areas treated
to obtain the expected results at an additional cost

On my own free will, I am requesting and providing my informed consent, to undergo
treatment(s) I understand that this is an elective procedure, performed solely for
cosmetic purposes, and is not critical to my health I assume all risks as my own I hereby
release them from any liability, both seen and unforeseen, now and forever.

April 22, 2021

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What procedure are you having done using "Clear" by Skin SheekTM? *
Please carefully read through and check off the following that you are agreeing too. *
I am not presently pregnant or lactating
I have not had any Botox in the past 2 weeks, or used retinoids for 3 or more days
I do not have a severe allergy to nickel
I am not on any blood thinners or high doses of aspirin
I have been informed of the possible risks and complications which may include, but are not limited to, infection, hyper-pigmentation, redness, edema, bruising.
I understand that this procedure will make my skin photosensitive and I must apply SPF 30 or higher 10 minutes prior to sun exposure
I do not currently or have a history or prior history of: Pace maker, keloid scarring, viral Infections, auto immune disease, vascular disease, cold sores (may cause slower healing time), anxiety issues, glycation, have taken Accutane in past 6 months
I have been given a copy of pre-care, post-care, and home instructions
I understand home care and maintenance are required to achieve optimal results
I agree to follow the post-care, and home instructions
I understand numbing is optional
Post treatment healing time is usually 7-10 days, it is highly recommended to purchase LuxMDTM post treatment medical balm, it will speed healing times
I understand the potential risks and complications and choose to proceed after careful consideration of the possibility of both known and unknown risks, complications, limitations and alternatives
Please select if you consent to the following:
I consent to the taking of photographs to monitor treatment results
I consent to before and after photographs of treatment being posted publicly

Please list any Medical Diagnosis:

Please list any Medications:

Please list any current medical treatments:
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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