informed consent for SWiCH dermal rejuvenation system Today's Date * MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### CONSENT FOR TREATMENT * I hereby give permission for my esthetician, Lee Haskin at eleven esthetics, to perform the Circadia SWiCH Dermal Rejuvenation treatment. Yes No I HAVE READ STATEMENTS 1-9 BELOW AND AGREE TO ALL OF THEM: * 1) I understand that the SWiCH™ Dermal Rejuvenation treatment is intended to improve the condition and appearance of my skin. I understand that the product has been thoroughly studied, clinical trials have been performed on a variety of skin types, and that clinical results may vary according to my own skin type and/or conditions. 2) 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 skin care 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 result of the SWiCH Dermal Rejuvenation treatment. 3) I am aware that I may experience possible short-term effects of reddening, mild stinging sensations, scabbing, feeling of tightness, and/or acne-like eruptions in the days following the treatment. 4) I understand there is a possibility of rare side effects, as there is with any product even if it has been proven safe and effective in clinical trials. Should I experience an extreme reaction to this treatment, I will contact my esthetician immediately to discuss a possible remedy. 5) If I have any questions regarding the procedure, I agree to contact my esthetician to discuss any concerns. 6) I understand the cost of the treatment and the fee structure has been explained to me. 7) I understand that I will be provided specific products by my esthetician following the treatment, and instructions for the use of these products have been explained to me. The clinically-demonstrated positive results of the SWiCH Dermal Rejuvenation treatment require my compliance with the application of these products. 8) 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 aspirin or any salicylic sensitivity - Allergic to citric fruits (oranges, grapefruit, lemons) - History of being “highly allergic” to anything - Pregnant, nursing, 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 - Recent peels within 8 weeks - Laser hair removal within 6 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 9) I consent to the taking of photographs to monitor treatment effect and results if desired by my esthetician. Yes No INFORMED CONSENT RELEASE In the event of any questions or concerns, I will consult my esthetician immediately. I understand the potential risks and complications, and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I will hold the esthetician and eleven esthetics harmless from any liability that may result from this treatment. 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. 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 SWiCH Dermal Rejuvenation System. * NOTE: This checkbox is equivalent to electronic consent & a legally binding agreement. Thank you!
