MedSpa Consent

This form is required to be read and signed before any procedure is performed. Please read each section of this consent form. Though you will not receive all forms of treatment in a single visit, you will likely advance to different levels of treatment and other forms of skin care services.
1. I have provided a complete and accurate medical and medication history to Salameh Medical Spa & Skin Care. I understand and agree that it is my responsibility to inform Salameh Medical Spa & Skin Care of any changes to my medical history prior to any future treatments. I understand that the following medical conditions are extremely important to disclose and I have indicated on my medical history if any apply to my health:
  - Use of Hormones/Hormone Pellets
  - Cancer
  - History of Skin Cancer
  - Pacemaker / Heart Conditions Active Collagen Disease
  - Use of Accutane
  - Clotting Disorders
  - Use of Birth Control
  - Cold Sores/ Herpes Simplex
  - Blood Thinning Medications
  - Surgical History
  - HIV
  - Pregnancy
  - Diabetes
  - Large Dental or Prosthetic Implants Anaphylaxis or Allergy to Lidocaine Neuromuscular disease
  - Trying to Conceive
2. I understand that I will be evaluated by a Nurse Practitioner, Registered Nurse or Licensed Aesthetician prior to the performance of any procedure to determine procedure acceptability and approval. Treatment plans will be prepared by the Nurse Practitioner, Nurse and/or a Licensed Aesthetician.
3. Payment is due at the time of treatment. No refunds will be given for any reason.
4. I understand that a tanning bed or sun exposure can negatively impact the healing, results, health of my skin and can cause unwanted side effects. Use of a broad-spectrum UVA/UVB sunscreen with SPF 30 or above is recommended and should be used during the entire treatment process. Sun and tanning beds should be avoided.
5. I have received and agree to follow the aftercare instructions provided by Salameh Medical Spa & Skin Care. I understand that and agree that I am fully responsible for any complications that arise from not following these instructions. If instructions are lost, they are available on the website (www.salamehplasticsurgery.com) or call the clinic at 270-904-7791.
6. Even though appropriate measures are taken to reduce side effects or complications, they cannot be completely eliminated. I am aware there are possible side effects, injuries or complications from the treatments I will receive which have been fully discussed with me and are listed below. I freely assume these risks. I am choosing the treatments requested in lieu of other procedures and understanding the risks.
LASER/ RF TREATMENTS

burns, blistering, pain, discomfort, scarring, excessive swelling, keloid, hyperpigmentation, hypo-pigmentation, purpura, textural changes, infection, sensitive skin, reduced sweating.

PRP / MICRONEEDLING/ RADIOFREQUENCY MICRONEEDLING

DISCOMFORT: Usually minimal and of short duration.
SWELLING: Occurs rarely and is usually minimal, typically subsides within a few hours or days. The skin may feel tight after the treatment. REDNESS: Redness may persist for a few hours to a few days.
CRUSTING/SCABBING: On rare occasions, a superficial crusting may occur, typically this is localized, but can be seen over larger areas.
PIGMENTATION: Although extremely rare, temporary or possibly permanent changes in color of the skin may occur.
MILIA: Whiteheads or acne may occur but will usually disappear quickly.
INFECTION: Infections are unlikely but may occur. An outbreak of fever blisters may occur in affected individuals. If you are prone to fever blisters, please inform your provider and a prescription will be provided.

CHEMICAL EXFOLIATION/ADVANCED RESURFACING/HYDRAFACIAL

Stinging, itching and irritation, Redness and possible swelling, Tightness, peeling, or scabbing of the treated skin and surrounding areas, Prolonged skin sensitivity, I understand that I may or may not peel and that the amount of peeling does not correlate with the degree of effectiveness or improvement.

Allergic reaction is uncommon from treatment. Some persons may have a hive-like appearance in the treated area. Some persons have localized reactions to cosmetics or topical preparations. Systemic reactions are rare.
Please initial in the space provided below once you have read the following terms:
I understand that treatments may require several treatments to achieve the best results.
I understand that waxing, dermal fillers, and Botox injections should be avoided for at least 7 days before and after laser treatments, microneedling, chemical peel or any other skin resurfacing treatments.
I agree to inform a Salameh Medical Spa & Skin Care provider when I begin new medications and/or products during the course of treatments. I agree to wear eye protection and will not remove the protection during appropriate laser procedures.
If you are scheduling a laser hair removal, IPL, BBL, radiofrequency, skin resurfacing, or tattoo removal please arrive clean shaven for your appointment. If you are not shaven prior to appointment additional fees will apply.
Before and after photographs will be taken and will become a part of my client record. Photographs are important for documenting my treatment course. I give permission for photographs to be used [anonymously] for marketing and advertising purposes as well as for education purposes including on the Salameh Plastic Surgery website.
Initial here if you would like to opt out of the use of photographs for marketing and advertising.
48 hours is required to cancel an appointment. If you or fail to cancel or reschedule your appointment within 48 hours or do not show up for your appointment you will forfeit the consultation fee or VIP complimentary treatment that was scheduled.
I understand that there is no guarantee of results. No promises or guarantees of results have been made by Salameh Medical Spa and Skin Care staff. I acknowledge that results vary from person to person. I further understand that follow-up treatments may be necessary for desired results. I understand that I may not see visible results as each case is individual.
I certify that:
I am not pregnant or breastfeeding
I have not used an isotretinoin (Accutane) in the past 12 months
I do not have a history of radiation to the treated area
I do not have active herpes simplex or active infection
I have not waxed in the area to be treated for the past 4-6 weeks
I have not used benzoyl peroxide for one week
I have not used Retin A or other similar medications for at least 4-5 days or longer
I have not used a scrub, had microdermabrasion or a peel in the last 72 hours
I understand that I may need a series of treatments to achieve maximum results
I agree to protect my skin from direct sun for 3 days post procedure and follow any recommended aftercare protocol
I will avoid hot baths/showers, tanning beds, use of self-tanners, sweating and strenuous exercise for at least 3 days post procedure
I will avoid rubbing, picking, scrubbing and scratching, my skin post procedure as this could lead to scarring
I will not use any exfoliating agents or retinoids until my skin has completely healed
I will keep the treated area clean, as I understand that the skin is susceptible to dirt and bacteria from hands touching the skin or other non-sterile contact, which could result in contact dermatitis, bacterial infection, or acne breakouts
By signing this form, you confirm that (i) you read, understand and agree to the above items, (ii) you have been fully informed regarding the procedure(s), risks and side effects, and (iii) you knowingly, freely and voluntarily give consent to have the procedure performed, Salameh Plastic Surgery & Medical Spa’s staff have fully explained the procedure to be administered. I have had a chance to ask questions which were answered fully to my satisfaction. Potential side effects have been explained to me. I understand there is no guarantee of results from the treatment and the possible risks associated. This consent, acknowledgement and understanding form is valid for every visit I make with Salameh Medical Spa and Skin Care.

I understand the procedure is elective and accept the risks. I hereby release Salameh Plastic Surgery & Medical Spa, its employees and contractors from all liabilities associated with the procedures performed. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained by any treatment or services. I agree any self-publication including posting, broadcast or transfer of personal information by you on the internet, a blog, website, or other printed /electronic form constitutes a waiver of any protections afforded such personal health information under any applicable regulations, rules or laws. Any self-publication of your personal information permits Salameh Plastic Surgery & Medical Spa to respond to the original publications to the extent necessary to defend, limit and challenge the assertions made in such publications. Any and all comments and publications will be considered self-disclosed waived protections of your personal information.

Acknowledgment:

I certify that I am a competent adult of at least 18 years of age. This consent form is binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assignees.
Patient’s Name (Printed)

Patient’s Name (Printed)
Patient’s Signature
Patient’s Signature
Witness

Witness

LASER/ RF TREATMENTS

PRP / MICRONEEDLING/ RADIOFREQUENCY MICRONEEDLING

CHEMICAL EXFOLIATION/ADVANCED RESURFACING/HYDRAFACIAL

Please initial in the space provided below once you have read the following terms:

Initial here if you would like to opt out of the use of photographs for marketing and advertising.

I certify that: