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Comprehensive Facial Consent Form

(Includes: Dermaplane, HydraGlow Facial, LED Light Therapy Facial, O2 + Ultrasonic Infusion Facial, Custom Lymphatic Detox Facial, Age Defy RF Lift Facial, Fusion Facial, Microneedling, SkinMedica Illuminize Peel, SkinMedica Vitalize Peel, and SkinMedica Rejuvenize Peel)

I consent to receive one or more of the following facial services today or in the future at this facility:

  • Dermaplaning (exfoliation using a sterile scalpel)
  • Chemical Peel (acid exfoliation for brightening, texture, and acne)
  • Lymphatic Buccal Massage (intraoral and external facial sculpting)
  • Microneedling with or without PRF (collagen stimulation using fine needles and/or my own growth factors)
  • Other customized facials or skin treatments recommended by my provider

I acknowledge and understand the following:

  • Risks: Redness, irritation, flaking, breakouts, temporary discomfort, hyperpigmentation, or rare complications such as infection or scarring may occur. I assume all such risks.
  • Downtime:
  • Chemical Peels: Peeling or redness may last 3–7 days
  • Microneedling: Redness and swelling may last 2–4 days; full healing in 5–7 days
  • Dermaplane/Buccal/Facials: Minimal or no downtime, but sensitivity is possible
  • Post-care: I agree to follow post-treatment instructions such as avoiding sun exposure, active skincare products, or makeup for the advised time period.
  • Medical Oversight: I understand that microneedling, chemical peels, and PRF involve medical supervision or delegation per Texas law. Other services may be performed by a licensed aesthetician.
  • PRF (if applicable): I authorize a blood draw to create Platelet-Rich Fibrin for topical application. I confirm I’ve disclosed any blood disorders, anticoagulant use, or allergies.
  • Contraindications: I confirm I have disclosed any of the following conditions (which may require provider clearance):
  • Use of Accutane or Retinoids within the past 6 months
  • Pregnancy or breastfeeding
  • Active cold sores/herpes simplex virus
  • Autoimmune conditions or uncontrolled diabetes
  • Recent laser, filler, or injectable procedures
  • Open wounds, sunburn, or infections in the treatment area
  • No Guarantee: I understand aesthetic treatments are not an exact science. While many clients experience improvement, results vary, and multiple sessions may be needed. No guarantee has been made regarding the outcome.
  • Payment & Cancellation: I agree to pay for services rendered and understand no refunds will be issued once treatment begins.

I have read this form carefully, had the opportunity to ask questions, and fully understand the risks, benefits, and alternatives. I certify that I am at least 18 years old and able to give legal consent.

PLEASE SIGN BELOW IF YOU AGREE



First Client's Name
First Name*
Last Name*
First Client's Date of Birth*
Date of Birth
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
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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 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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