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Treatment Screening and Consent

Birthday
Month
Day
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Risk Screening

Have you had any of the following in the last 2 weeks?
Have you used any of the following products in the last 3 days?
Are you pregnant, trying to conceive, or breastfeeding?
Yes
No
Do you have any metal implants such as a pacemaker?
Yes
No
Do you currently have a neck/back injury or pain?
Yes
No
Do you have any active cold sores, facial warts, or broken skin on your face?
Yes
No

Consent to Treatment

Authorization & Services I hereby consent to and authorize Becky Eder to perform skincare treatments and clinical consultations. I have voluntarily elected to undergo these services after their nature and purpose have been explained to me. I recognize there are no guaranteed results; outcomes are dependent upon age, skin condition, and lifestyle. I understand that skincare advice and treatments are progressive, and further sessions may be required at an additional cost to obtain expected results.

Professional Advice & Scope I understand that the information provided during a consultation is for educational and aesthetic purposes. While the advice is based on clinical skincare science, it does not replace the advice of a medical doctor or dermatologist. I agree to consult with a physician regarding any medical concerns or before starting new prescription-grade products.

Medical History & Disclosure I have provided an accurate account of my medical history, including all known allergies, prescription drugs, or topical products I am currently using. I do not hold the esthetician responsible for any conditions that were present but not disclosed at the time of this service which may be affected by the treatment or product recommendations provided today.

Post-Service Care & Products I understand the importance of following all instructions given to me for home care and product usage. I agree to consult my esthetician immediately if I have additional questions or concerns regarding my treatment, suggested home products, or skin reactions.

Acceptance of Risk I have read and fully understand this agreement. I understand the services provided and accept the inherent risks of topical skincare. All of my questions have been answered to my satisfaction, and I hereby consent to the terms of this agreement.

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