Removal of Skin Irregularities

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Removal of Skin Irregularities is used for Cosmetic purposes only and can be used to remove cosmetic imperfections. To remove skin irregularites a Super Frecator Machine is used. It uses high frequency to target skin imperfections. A scab will form after the treatment and typically falls off in 7-10 days.
Health History
Please check if you have any of the following conditions*
Check all that apply, if none, click none of the above
- Currently Pregnant or Nursing
- Metal Implants in or near the treatment area, Extreme amount of dental implants, braces, caps, metal filings
- Recent Botox or Fillers in the Treatment Area? (within last month)
- Pacemaker or internal defibrillator, implanted neuro-stimulators or other internal electric device
- Current or history of cancer- especially skin cancer, or pre-malignant moles in treatment area
- AIDS/Lupus or other Auto Immune disease
- Cold Sores/Herpes or Shingles
- Wounds or skin conditions in the area to be treated
- Radiation to the area within last six months
- Chemotherapy within the last year
- Any Cardiac Conditions
- Accutane use within a year
- Epilepsy
- Do you take Heart Medication
- Do you take Prednisone
- Retinol or Alpha Hydroxy Acids use on the area within the last weeK
- Are you using any Acne Medications (Topical or Cream)
- None of the Above
If you checked any of the boxes above, please provide more information here
Please Describe the area to be treated*
Please indicate location on the body and a description of the type of skin irregularity (ie. skin tag, mole, sun spot etc.)
Please Read and check the box below*
I will ask my esthetician any questions I have about the procedure. I have been
advised that though good results are expected, complications cannot be anticipated and that therefore there can be no guarantee, either expressed or implied, as to the results of the treatment.
I understand that possible complications post treatment might include hypo pigmentation (lighter skin color where growth was removed), infection if I scratch treated area before it is healed, or possible scarring if I am prone to Keloid scarring.

I understand that all precautions will be taken to ensure the best possible results but I understand my skin may not react the same as most and therefore I cannot hold Celebrity Skin Studio it’s owners, employees or voulunteers (hereafter referred to as CSS) liable for unforeseen outcomes. I am aware
that I am accepting this treatment at my own risk and that CSS shall be released of all responsibilities and liabilities
should the treatment with the Super Frecator machine cause any adverse results.

I understand that to acheive the best results I should follow the home care recommendations of my esthetician.
I understand and agree to the above
PRE & POST Treatment Instructions
BEFORE Your Treament Advise your esthetician if you have had any recent treatments in the area to be treated. Discontinue any Retinols or Alpha Hydroxy Acid products at least 1 week prior to appointment. If you take any medications, orally or topically for any Acne or Skin conditions please consult with your esthetician prior to scheduling.
AFTER your Treatment: Keep the area dry. Do not apply anything to the area including products or ointments etc. It’s important to preserve the scab as long as possible. Do not pick at the scab, and be careful when dressing etc. to not disrupt the scab. The scab will typically fall off in 7 to 10 days. If it does come off prematurely it can result in red or pink discoloration and can cause scarring. Once the scab comes off it’s important to wear sunscreen to protect the area and help prevent disoloration.
Consent*
I understand the pre and post treatment instructions and agree to follow the directions and recommendations of my esthetician.
Consent for Treatment & Liability Waiver
Consent for Treatment and Liablity Waiver*
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand 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 been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.
- By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver
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Removal of Skin Irregularities

Health History

PRE & POST Treatment Instructions

Consent for Treatment & Liability Waiver