Today's Date *

MM

DD

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Name *

First Name

Last Name

Phone *

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CONSENT FOR TREATMENT *

I hereby give permission for my esthetician, Lee Haskin at eleven esthetics, to perform the following Circadia treatment(s) (select all that may apply):

Oxygen Rx Treatment

Cocoa Enzyme

Raspberry Enzyme

Zymase Enzyme

I HAVE READ STATEMENTS 1-13 BELOW AND AGREE WITH ALL OF THEM *

1) I agree to complete a confidential skin health questionnaire. I agree to be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skincare regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlled substances, will affect and diminish the effectiveness and results of the treatment. 2) I have disclosed to my esthetician any surgical procedures, laser treatments, or facial procedures that I have had or intend on having in the future. 3) I am not presently pregnant, nursing, or lactating. 4) I have not had any recent chemotherapy or radiation treatments. 5) I have not recently waxed or used a depilatory (such as Nair) on the area being treated. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters, or cold sores. 6) I understand that I should not have a treatment if I intend to be in the sun or use a tanning bed, and will refrain from excessive sun exposure and the use of a tanning bed while I am undergoing treatment. 7) I have disclosed to my esthetician any and all treatments of any kind that I have received within 14 days of this treatment, whether the treatment was performed at this location or any other location. 8) I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complication, I will immediately contact the esthetician who performed the treatment. 9) I understand that the following conditions preclude me from having this treatment at this time, and verify that none of these conditions currently apply to me: - Allergic to citric fruits (oranges, limes, grapefruit, lemons) - Allergic to cocoa, chocolate, and/or raspberry - Allergic to pineapple and/or papaya - History of being “highly allergic” to anything - Pregnant or lactating - Current use of antibiotics (topical or systemic) - Current use of glycolic acid products - Use of Accutane® within the past 12 months - Laser resurfacing surgery within the last 12 weeks - Laser hair removal within 6 weeks - Recent peels within four weeks - Use of Retin-A®, Renova®, retinoids (Vitamin A) in the last 4 weeks - Broken skin on areas to be treated - Visible inflammation or inflammatory lesions - Herpes virus (cold sores) on mouth - Currently undergoing chemotherapy or radiation treatments 10) I understand the cost of the treatment and the fee structure has been explained to me. 11) My expectations are realistic; I understand that the results are not guaranteed, and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, my age, degree of sun damage, and/or pigmentation levels. 12) I understand that my esthetician will recommend home care products to work in tandem with the in-clinic/in-studio treatment. I am willing to follow recommendations by my esthetician for home care, including a sunscreen. 13) I consent to the taking of photographs to monitor treatment effect and results if desired by my esthetician.

Yes

No

By checking the box below and submitting the contents of this form via the 'send' button, I agree to the terms of this Informed Consent for Oxygen Rx and Enzymes Treatment form. *

NOTE: This checkbox is equivalent to electronic consent & a legally binding agreement.