Please read this authorization carefully and acknowledge your understanding by initialing and signing designated spaces.
As a client, you possess the entitlement to receive comprehensive information regarding the forthcoming services, encompassing its associated risks and advantages. This authorization and consent document has been designed with the intent of enhancing your level of awareness. To facilitate this, I strongly recommend that you inquire about any queries you may harbor. Furthermore, you are encouraged to independently investigate or seek guidance from your personal healthcare provider should you harbor supplementary inquiries.
Microcurrent Facial Toning entails the application of a non-invasive, low-level electrical current, which replicates the body's innate electrical impulses. This stimulation promotes the generation of ATP (Adenosine Triphosphate), a critical factor in the body's healing and rejuvenation processes. When combined with specialized products and manual techniques, these minuscule microcurrent impulses serve to enhance the body's natural electrical flow. This, in turn, leads to a significant reduction in the visible signs of aging, while concurrently enhancing skin tone and elasticity to a remarkable degree.
Guideline for Achieving Optimal Results
Age 35: 5 sessions over two to three weeks
Ages 35-50: 10-15 sessions over four to seven weeks
Ages 50+: 15 sessions over five to seven weeks
After completing the series, maintain a monthly schedule for optimal outcomes.
Microcurrent services are contraindicated for any of the following reasons:
- Cancer
- Seizure
- Epilepsy
- Phlebitis
- Pregnant
- Thrombosis
- Heart Condition
- Cardiac pacemaker
- On anabolic steroid
- All infectious illnesses
- Metal implants anywhere in the face
- Drugs or topical application causing thinning of the skin
The purpose of Chemical Peels is to enhance the texture and aesthetics of your skin.
Chemical Peels are contraindicated for any of the following reasons:
Rashes
Sunburn
Dermatitis
Active warts
Open wounds
Herpes simplex
Active cold sores
Excessively sensitive skin
Allergies (that react to peels)
Chemotherapy within the past year
On Accutane within the past year
Radiation therapy within the past year
Inflammatory rosacea in the area to be treated
Salicylic peels are contraindicated for any of the following reasons:
Allergy to salicylates (i.e. aspirin)
Pregnant or breastfeeding (lactating) women
Potential Adverse Effects of Chemical Peels
The examples provided herein serve as illustrations and are not meant to constitute an exhaustive catalog. Every individual varies, and it is important to acknowledge that more severe side effects may still manifest. Among the observed side effects, we have listed the most prevalent ones for your reference.
Swelling of the face and/or treated area may occur.
The epidermis may become red (similar to sunburn), blister, and/or crust before healing.
The peeling process typically lasts one day to one week but can vary based on the individual.
There is a potential risk of developing pigmentation changes in the treated area, which may be temporary or persistent.
Rare instances of allergic reactions to the peel or post-service creams may occur, which in extremely uncommon cases, could result in scarring.
Some discomfort may be experienced during and after the procedure, including sensations such as stinging, pinpricking, hotness, and tightness.
Potential Complications, but not common
The preceding enumeration is not intended to serve as an exhaustive or comprehensive compilation of all potential complications that could result from the procedure(s). In the event that any of the aforementioned complications occur, please promptly inform us.
Demarcation: A variation in color, texture, or pigmentation may manifest at the boundary between the treated and untreated skin areas. Such occurrences are infrequent in epidermal procedures.
Enhanced Visibility: Preexisting blemishes, temporarily moles, blood vessels (telangiectasia), freckles, and sun spots may become more noticeable and appear darker following the removal of dead skin layers.
Eye Hazards: There is a risk of eye injury due to the introduction of chemicals into the eye, potentially resulting in scarring and disturbances in vision.
Milia Formation: Milia may develop but generally resolve quickly.
Infection Risk: While the likelihood is extremely low, infection may occur.
Herpes Outbreak: Individuals prone to cold sores may experience a herpes outbreak, for which it is advisable to consult a physician for medication.
Dermaplaning is a physical exfoliation technique that eliminates dead skin cells and vellus hair from the surface of the face. This exfoliation method results in skin smoothing and facilitates enhanced absorption of active ingredients in skincare products and services, thereby heightening their effectiveness and anti-aging advantages.
Dermaplaning is contraindicated for any of the following reasons:
Cancer
Diabetes
Active Acne
Bleeding disorders
Blood thinner medications
Higher dosages of Aspirin
Inability for blood to coagulate following injury
Accutane due to increased sensitivity and/or the possibility of delayed clotting from a nick or cut
The Celluma device has been approved by the FDA for multiple indications. The Celluma has 345 light emitting diodes that emit light energy at blue (465 nm), red (640 nm) and near-infrared (880 nm) wavelengths with frequencies of 80 Hz, 680 Hz and 800 Hz respectively for a duration of 30 minutes per service. There is a broad range of optical parameters reported to induce specific biological responses resulting in improved therapeutic outcomes.
LED is contraindicated for any of the following reasons:
Pregnancy
Breastfeeding
Steroid Injections
Infants or Children
History of Epilepsy
History of Seizures
Cortisone Injections
Photosensitive drugs
This procedure entails the removal of unwanted hair. Warm to hot wax is applied to the skin, followed by the pressing of a cloth or paper strip into the wax preparation. Subsequently, the strip is swiftly removed, taking hairs along with it. Commonly observed side effects are as follows:
Antibiotics Sensitivity: It's important to note that taking antibiotics may increase skin sensitivity and make it more susceptible to slight skin lifting during the waxing process.
Potential Skin Reactions: Please be aware that waxing may result in localized inflammation, welts, hives, reddening, or minor breakouts. These reactions can occur due to the extraction of bacteria from beneath the skin's surface along with the hair, or due to sensitivity or allergy to the wax. Typically, these reactions are not severe and tend to subside within a few days.
In case of a reaction, we recommend taking the following steps:
Apply a topical antibiotic, such as Neosporin.
Use cold compresses to reduce inflammation.
Avoid sun exposure and use sunscreen with a minimum SPF of 25 or higher to protect the treated area.
I hereby grant authorization to Skin Fit Rox, LLC and its owner to conduct Microcurrent Facial Toning, Peel, Dermaplane, LED, and/or Waxing services on my person.
I am completely aware that these services have limitations. I acknowledge that reputable practitioners cannot offer a specific outcome, or the absence of complications. I have not received any such guarantees.
I acknowledge that I have had the opportunity to seek clarification by asking questions, and I possess a comprehensive understanding of the Microcurrent Facial Toning, Chemical Peel, Dermaplane, LED, and Waxing services. I recognize that these services are classified as cosmetic, and I bear full responsibility for covering all associated costs of the procedure and any related services.
RELEASE OF LIABILITY - To the maximum extent allowed by law, I, the undersigned, agree to waive and release any and all claims, suits or related causes of action against Skin Fit Rox, LLC, its owners, officers, employees, or agents, for negligence, injury, loss, death, costs, or other damages to me, my heirs or assigns, while on the premises of 810 Walnut Street, Edmonds WA 98020 or participating in any off-site Skin Fit Rox, LLC program or activity.
ASSUMPTION OF RISK - I understand and acknowledge there are risks involved with skincare services and treatments. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive Skin Fit Rox, LLC’s liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby waive Skin Fit Rox, LLC's liability if such results or complications occur. In consideration for Skin Fit Rox, LLC performing this procedure, I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me and/or my family while undergoing this procedure or side effects that may be experienced after the procedure is performed. I understand that the service provider does not diagnose illness, disease, or any other physical or mental conditions. The provider also does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal adjustments. Spa and Skincare services are not a substitute for medical examinations and diagnosis. It is recommended that I see a physician for any physical or mental ailment that I might have. Any sexual misconduct exhibited by the Client will result in immediate termination of the session, and the client will be liable for payment of the scheduled appointment. If I cancel, reschedule, or skip an appointment without 48 hour's notice, I agree to forfeit the full session fee.
INDEMNIFICATION - I agree I will indemnify, defend and hold Skin Fit Rox, LLC and it’s owners harmless, to the maximum extent allowed by law, from negligence, injury, loss, death, costs or other damages to me, my heirs or assigns, or third parties for claims, suits, or related causes of action asserted against Skin Fit Rox, LLC or it’s owners arising from my conduct and/or my family's conduct while on the premises of Skin Fit Rox, LLC.
APPLICATION - I agree that this Waiver and Release of Liability ("Release") shall apply to each visit I make to Skin Fit Rox, LLC, including future visits, regardless of any date of issuance or expiration date, and regardless of the date that this form is signed below.
AGREEMENT TO COMPLY WITH RULES - I agree to, and will comply with, Skin Fit Rox, LLC’s Policies as posted. I acknowledge Skin Fit Rox, LLC’s Policies are subject to change at the sole discretion of Skin Fit Rox, LLC.
BINDING ON OTHERS - This Release shall bind the members of my family and my spouse or registered domestic partner, if I am alive, as well as my estate, family, heirs, administrators, personal representatives or assigns if I am deceased and shall be deemed as a "Release, Waiver, Discharge and Covenant" not to sue Skin Fit Rox, LLC.
SEVERABILITY - I agree that the purpose of this Release is that it shall be an enforceable release of liability and indemnity as broad and inclusive as is permitted by Washington law. I agree that if any portion or provision of this Release is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid portion will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the Release.
APPLICABLE LAW, FORUM & ATTORNEY'S FEES - This Release is governed by and shall be construed in accordance with the laws of the state of Washington, without any reference to its choice of law rules. I agree that any dispute arising from this Release or in any way associated with Skin Fit Rox, LLC shall be brought only in the Superior Court of Snohomish County, Washington, or in the U.S. District Court for the Western District of Washington, and I agree to the jurisdiction and venue of those courts for any such dispute. In any litigation in which the validity or enforceability of this Release is contested, I agree that the substantially prevailing party will be entitled to receive all attorney's fees and costs from the party contesting the validity of this Release.
INTEGRATION - This Release, in conjunction with any Membership Agreement, encompasses the entire agreement of the parties, and supersedes all previous understandings and agreements between the parties, whether oral or written. I acknowledge that no oral representations, statements or other inducements to sign this Release have been made apart from what is contained in this document.
I ATTEST that I have thoroughly read and comprehended the preceding paragraphs, that I have had ample opportunity for discussion and to seek clarification by asking questions, and that I provide my consent to the procedure delineated above. I have taken it upon myself to acquaint myself with the contents of this release by carefully reading it prior to signing. Through my signature below, I acknowledge and consent to the terms and conditions outlined above.
The information provided above is entirely truthful and precise to the best of my knowledge. I accept full responsibility for promptly notifying my practitioner of any physical or mental condition that could impact my service or outcomes. I am cognizant of the necessity to inform my practitioner about any alterations in my health status. Furthermore, I comprehend that these services do not serve as medical treatment.
If client is a minor, signature of parent or responsible adult is required.
PARENTAL RELEASE OF LIABILITY - In consideration of the minor child being permitted to utilize Skin Fit Rox, LLC’s facilities, I accept and agree to the full contents of this Release.
PARENTAL INDEMNIFICATION - I agree to release, indemnify, defend and hold Skin Fit Rox, LLC and its owners harmless from all liabilities and future claims presented by my children or any other minor children and/or their parents, for any injuries, losses or damages to themselves or any family member or registered domestic partner. This includes any claim of the minor and any claim arising from the negligence of Skin Fit Rox, LLC.
PARENTAL REPRESENTATION OF AUTHORITY - I agree that I am authorized to sign this Release on behalf of the child by all of the parents and/or legal guardians of the child. I represent that all parents and/or legal guardians of the child know of and acquiesce to the signing of this Release and agree to waive and release any and all claims, suits or related causes of action against Skin Fit Rox, LLC and its owner.
I have fully informed myself of the contents of this release by reading it before signing it.
By my signature below I understand and agree to the above terms and conditions.
