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RELEASE OF LIABILITY AND WAIVER FOR MICRONEEDLING WITH EMILY LETOURNEAU AT TREAT LLC

I authorize Emily LeTourneau, tenant at Treat LLC, to perform Microneedling on my skin using The Exceed Device by Candela. I understand that topical preparations may be applied as needed, including the AnteAGE Microneedling Solution and/or a lidocaine-based numbing cream or gel.

I acknowledge that Microneedling is a non-ablative cosmetic treatment designed to promote skin rejuvenation by creating controlled micro-perforations in the skin. I understand that results vary between individuals and cannot be guaranteed.

I am aware that possible short-term side effects may include redness, peeling, scabbing, temporary bruising, and temporary discoloration of the skin. I also understand that rare but potential risks include infection, scarring, or allergic reactions. I certify that I have disclosed any known allergies or medical conditions that may affect my treatment.

By signing this waiver, I confirm that the nature and purpose of this treatment have been explained to me, that I have had the opportunity to ask questions, and that all of my questions have been answered to my satisfaction. I release and hold harmless Emily LeTourneau and Treat LLC from any and all liability for complications, side effects, or undesired results that may occur in connection with Microneedling or the use of topical preparations.

I understand that I have the right to refuse treatment at any time. My signature below indicates that I voluntarily assume all risks and agree to proceed with treatment under these terms.

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Do you take any of the following?
Check all that apply:
Asprin or blood thinners
Anti-inflammatory medications or steriods
Vitamin A or E
Have you used any of the following products and/or had any of the procedures listed below in the last 4 weeks??
Check all that apply:
Retin-A, AHA, or other exfoliating topical products
Botox and/or injectables
Laser treatments or chemical peels
Cosmetic Tattooing
Cosmetic surgery on the area to be microneedled
Are you allergic to any of the following?
Check all that apply:
Metal
Topical anesthetics (Examples are Benzocaine Lidocaine Tetracaine)
Asprin
Do you have a history of cold sores, herpes, or fever blisters?
No
Yes
Do you have any allergies?
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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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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