Stem Cell Facial

Name

First Name

Last Name

Informed Consent:

I understand that if I am prone to keloid scarring or any abnormal scarring conditions, have skin that is prone to topical allergies, reactions, or irritations, or if I tend toward histamine reactions or have substantial seasonal allergies or have allergy-induced-asthma or other significant allergies, or have a history of facial herpes, or an active infection (fungal or other), or have active warts, active acne, skin cancer, or am receiving chemotherapy or have uncontrolled diabetes, then the Stem Cell Facial is not the best possible treatment for my skin, and I will inform my Rich Earth Organic Skin Care practitioner that I should not have this treatment and will either forgo a facial/treatment or opt for a facial/treatment that has no known contraindications for my skin.

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 of 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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Rich Earth Organic Skin Care Studio recommends using the AnteAGE Serum and Accelerator for a minimum of two weeks prior and two weeks after receiving the Stem Cell Facial Treatment.

Skin Care Note: The natural plant antioxidant flavonoids quercetin and bromelain can be helpful (such as found in the supplements Ortho Molecular Natural D-Hist and Vital Nutrients Aller-C) for histamine reactions. If needed/desired, check with you healthcare practitioner if these supplements are a good option for you.