Microcurrent Treatment

Informed Consent & Release of Liability

Name

First Name

Last Name

Informed Consent:

I understand that if I have any of the following conditions, I will inform my Rich Earth Organic Skin Care practitioner that I should not receive a microcurrent treatment and will either forgo a facial/treatment or opt for a facial/treatment that has no known contraindications for my skin:
- pacemaker or other implanted, electronic devise
- metal implant (pins, plates) in area to be treated
- epilepsy
- cancer
- thrombosis
- phlebitis
- pregnancy
- under a physician’s care for a disorder, illness, disease or injury
- severe or cystic acne - severe, inflamed rosacea
- any untreated, acute, inflammatory skin condition

*If you have facial injections (Botox, filler, etc.,) the injections must be received at least two weeks prior to receiving a microcurrent treatment.

Release of Liability:

By signing this agreement, I am confirming I understand there may be inherent risks associated with receiving facials/treatments and using skin care products, including those provided by Rich Earth Organic Skin Care Studio. I acknowledge and agree I am responsible for my own health; that Rich Earth Organic Skin Care Studio and Rich Earth Organic Skin Care Studio practitioners cannot be expected to diagnose and/or treat individual health problems. By voluntarily choosing to receive facials/treatments and/or use skin care products, I warrant that to the best of my knowledge, I have no condition that is contraindicated for receiving such facials/treatments and using such skin care products. I understand it can be impossible to guarantee or predict a specific aesthetic outcome, so no such guarantee has been made to me. I also understand it can be impossible to predict who may have an unexpected, adverse reaction to a facial/treatment or skin care product, and as such, I acknowledge that I am choosing to receive facials/treatments and to use skin care products of my own free will, with the complete understanding that I cannot hold Rich Earth Organic Skin Care Studio responsible for any inherent risk or unexpected adverse reaction that could occur. In light of the foregoing, I hereby release Rich Earth Organic Skin Care Studio and its practitioners and waive any and all claims, liabilities, or damages for personal injuries that I may experience directly or indirectly from receiving facials/treatments or using skin care products provided by Rich Earth Organic Skin Care Studio.

Date

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