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Facial Client Informed Consent Form

Let us do this part
Today's Date:
Sun May 18 2025 08:50
Please read and answer
Y
N
Please review the listed contraindications and confirm that you do not have any of the following:*
* Pregnant or nursing woman
* Epileptic
* Use a pacemaker
* Have a muscular or nervous disease
* Being treated for cancer
* Have orthopedic implants
* Uncontrolled diabetes
* Facial paralysis
Details:
 
Y
N
I have no allergies to anything that I am aware of.*
Details:
 
Y
N
I understand that I must inform my technician if there are changes to my medical history, during my series of Bela MD treatments.*
Y
N
I clearly understand and accept the following:*
1. The goal of these treatments, as in any cosmetic procedure, is improvement, not
perfection. I understand my results might not be perfect, and the number of treatments may
vary.
2. There may be more treatments necessary than I anticipated.
3. There is no guarantee that expected or anticipated results will be achieved.
Y
N
I understand that I might experience a scratchy, stinging sensation during the treatment.*
Y
N
I understand that after the treatment my skin may appear red, which will dissipate in a few hours or less, depending on my skin’s sensitivity.*
Y
N
I acknowledge that if I fail to apply an SPF (sunscreen) after treatment, that I will be more susceptible to sunburn and hyperpigmentation.*
Y
N
I understand that during my treatment the use of medium frequency electromechanical stimulation and electroporation will be applied, I may sense involuntary muscle contractions and a pins and needles type sensation.*
Y
N
I confirm that I have not been on Accutane for acne therapy in the last 6 months.*
Y
N
I have read and understand the informed consent form and agree to treatment. I hereby give consent to receive the belaMD treatment performed by Skin Care Laser YXE.**
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:
Postcode:
Date of birth:*
Phone #:
Email:*
Signature:*