Before your Skin Classic or Microdermabrasion treatment,
please complete this consent form.
Your esthetician will answer any questions before you begin.
Personal Information
Let's start with the basics.
Please enter your full name.
Treatment Type
Which treatment are you consenting to today? *
Please select a treatment type.
Consent Agreement
Please read carefully and initial below.
The undersigned acknowledges that Stephanie A. Cirrito has explained
the nature of the above treatment procedure, including the risks and dangers inherent, such as:
infection, hyper or hypo pigmentation, redness, edema, or bruising. As in any cosmetic procedure,
the treatment goal is for esthetic improvement, not perfection. The number of treatments necessary
will vary between individuals and the areas being treated. Several factors including skin color, age,
hormonal activity, inherited conditions, and other influences may decrease effectiveness of treatments.
I hereby consent to Stephanie A. Cirrito performing the selected treatment on me, and in consideration of their doing so, I hereby release and forever discharge Dermagal Esthetics & Spa LLC from all claims, demands, damages, action or cause of action arising out of the performance of the said treatment procedures. No refunds on treatments.
Please enter your initials to continue.
Signature
By signing below, I consent to receive the selected treatment and agree to the terms stated in this form.
Please sign above to continue.
✓
Thank you, there!
Your consent form has been submitted.
Please hand the iPad back to your esthetician.
Esthetician Sign-Off
Treatment:— Date:—
Pro section stays on this device and is not submitted.
