Silhouet-Tone EVOLUTION 5HD - Evolution 5 HD Treatment Release Form

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09.Evolution 5HD treatment release form

Client/patient consent to treatment:

My signature below and my initials at each paragraph acknowledge that I have read the

following statements and agree to receive Electrolysis treatments.

I, ________________________________ authorize ______________________________

or member of her (or his) staff, to perform electrolysis treatments on myself.

Areas to be treated:

The nature and purpose of the treatment have been explained to me, and any questions I have

regarding this procedure have been explained to my satisfaction __________ (initials)

! I do not have any of the conditions (Pacemaker, metallic implant, diabetes, pregnancy,

medical condition delaying healing process, blood thinning drugs) contraindicated with

electrolysis treatments __________ (initials)

! I understand that with any treatment, certain risks are involved and that complications or side

effects from known or unknown causes can occur.

I freely assume these risks __________ (initials)

! Side effects might include mild redness, extreme redness, local swelling and stinging. Most

side effects are temporary and generally subside within one week to 21 days __________

(initials)

! I have been advised not to touch or rub treated areas, not to pick scabs, to let them fall off by

themselves. I understand that I must keep the treated area clean and use hydrating and

healing products, avoid sun exposure for one week and use total sun block on treated area

until complete healing. __________ (initials)

! I have received a copy of Post-Care instructions __________ (initials)

! During cold sores, inflammatory acne or other eruptions, it is necessary to discontinue the

treatment to avoid spreading the eruption. The procedure should be deferred until the skin is

perfectly healed. __________ (initials)

! I am over 18 years old __________ (initials)

I have read the above explanations and treatment recommendations and understand the potential

risks and benefits of treatments.

Client name______________________________Signature______________________________

Telephone

#__________________________________Date_________________________________

Witness name______________________________Signature____________________________