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Combined Consent Form for Skin Care Treatments

This is a combined consent form for Microdermabrasion, Dermaplaning, Chemical Peel, Waxing and Electric Modalities. We ask to sign this form every 12 months. Please put a check mark next to the service you are scheduled to receive and any additional services for future consideration to ensure no further paperwork will be needed until its 1 year expiration.

My esthetician has provided information and answered any questions I have regarding my treatment: expectations, contraindications, allergies, side-effects (bruises, scabbing, scarring, redness, swelling, tenderness, hyperpigmentation, break outs, flare up, dryness/dehydration, peeling, itchiness, irritation, edema, erythema, stinging, burning, nicking, cutting), pre and post care, and precautions. In the event that I may have additional questions or concerns regarding my treatment or suggested home products, post treatment care, I will consult with my esthetician immediately.


I acknowledge there are no guarantees as to the results of the treatment, due to many variables, such as: age, condition of the skin, sun damage, hormones, lifestyle, climate, etc.


I acknowledge that to achieve maximum results, I may need several treatments as follow post treatment care at home recommended by the estehtician.


I acknowledge that I must avoid direct sun exposure following this procedure and will apply sunscreen daily at least for 2 weeks following the treatment.


I acknowledge to inform my esthetician about any changes in my skin care, medications, and health conditions prior to the treatment.


I give permission to my esthetician to perform the service we have discussed and will hold her and Sage Wellness Spa harmless from any liability that may result from this treatment.


I certify that I have read and fully understand this consent form for treatment and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.


April 28, 2024

First Client's Name

First Name*

Last Name*
First Client's Age Acknowledgment*
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
Email me a copy of this document.
Description of Services and Contraindications
Please check the service you have scheduled for or would like to schedule in the near future. *
Microdermabrasion* is a minimally invasive form of manual exfoliation. It uses pressurized suction and diamond tips to remove the outer layers of dead skin cells.
Dermaplaning* is a manual exfoliation technique that removes debris and vellus hair with a custom dermaplaning blade.
Chemical Peel* uses a chemical solution to improve the texture and tone of your skin by removing the damaged outer layers.
Waxing* is the process of removing unwanted hair from a part of the body by applying wax and peeling off the wax and hairs togeTher.
Electrical Modalities** (Microcurrent Device, High Frequency, Ultrasonic Spatula, Red Light Gua Sha Device)
*Contraindications for Microdermabrasion, Dermaplaning, Chemical Peel and Waxing:
  • Ingredient allergies
  • Active facial rashes
  • Open or unidentified lesions (Herpes Simplex/Cold Sores)
  • Any type of dermantitis, including eczema, psoriasis and seborrhea
  • Sun exposure (2 weeks before and after scheduled treatment)
  • Weakened immune system
  • Serious illness
  • Pregnancy or lactating (applied for Chemical Peels)
  • Accutane usage (must be off accutane for 1 year to receive any of the above services)
  • Diabetes
  • High Blood Pressure (if you have this condition, please check with your Physician prior to receiving the desired service if it is safe for you to do so)
  • Heart Disease (if you have this condition, please check with your Physician prior to receiving the desired service if it is safe for you to do so)
  • Waxing (have to wait 3-5 days after waxing to receive microdermabrasion, chemical peel or dermaplaning)
  • Botox (you have to wait 1 week before and after to receive any services mentioned above)
  • Injectables (you have to wait 2 weeks before and after to receive any services mentioned above)
  • Microblading (you have to wait 2 weeks before and after to receive any services mentioned above)
  • Permanent Makeup (you have to wait 3-4 weeks before and after to receive any services mentioned above)
  • IPL (you have to wait 2-4 weeks before and after to receive any services mentioned above)
  • Laser Resurfacing (you have to wait 3-6 months before and after to receive any services mentioned above)
  • Cosmetic Facial Surgery (you have to wait 3-6 months before and after to receive any services mentioned above)
**Contraindications for Electrical Modalities:
  • Epilepsy or subject to seizures
  • Recent surgery
  • Pacemaker or electrical implanted device
  • Active cancer
  • Pregnancy
  • Under the age of 18


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*
Parent or Guardian's Age Acknowledgment*
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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