Informed Consent: Microcurrent

First Name

Last Name

Date / Time

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I understand there are certain contraindications that would preclude me from receiving microcurrent treatments, including autoimmune disorders, diabetes, embolism, epilepsy, melanoma, metal implants including plates/pins/screws, open wounds, pacemaker use, phlebitis, pregnancy, thrombosis, and varicose veins. *

I have read, consent, and understand

I understand that the use of Botox®, Juvederm®, Restylane®, and any other injectable must be disclosed prior to treatment. *

I have read, consent, and understand

I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk. *

I have read, consent, and understand

I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations. *

I have read, consent, and understand

I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure. *

I have read, consent, and understand

I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made. *

I have read, consent, and understand

I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History. *

I have read, consent, and understand

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. *

I have read, consent, and understand

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure. *

I have read, consent, and understand

I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes. *

I have read, consent, and understand

I understand that if I have any concerns, I will address these with my technician. I give permission to Crystal Reiki & Healing by Sheena, LLC to perform the microcurrent procedure we have discussed, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult Crystal Reiki & Healing by Sheena, LLC immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. *

I have read, consent, and understand

Disclosure. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Crystal Reiki & Healing by Sheena, LLC does not guarantee any specific result. The RF (Radio Frequency) treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemia, hyper-cholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. The RF (Radio Frequency) treatment includes, but is not limited to, the use of high-power low-frequency RF (Radio Frequency) which uses 25-28KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane. After Care. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment. Before, During and After Pictures. Before, during and after pictures or videos may be taken to document the treatment. These pictures s or videos become Crystal Reiki & Healing by Sheena, LLC sole property and may only be used for its legitimate business purposes. Release. I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Crystal Reiki & Healing by Sheena, LLC (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Crystal Reiki & Healing by Sheena, LLC. or other third parties, or in any way arising out of the above described treatment I have requested Sheena Apostolopoulos to perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Crystal Reiki & Healing by Sheena, LLC including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Pennsylvania law. I agree to indemnify, hold harmless and defend Crystal Reiki & Healing by Sheena, LLC, LLC (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Crystal Reiki & Healing by Sheena, LLC to perform. By signing this agreement I confirm that I am over the age of 18, I understand that the RF (Radio Frequency) procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs; had the procedure and risks explained to me, fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the RF (Radio Frequency), Coolsculpting, RF, and any other noninvasive procedure which is to be performed at my request according to this agreement and I herby agree to wave any arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights. *

I have read, consent, and understand

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