Diamond Glow Patient Consent Form

I certify that I am a competent adult of at least 18 years of age

I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.

I acknowledge that I might experience a scratchy, stinging sensation during the treatment.This sensation will subside during the post-treatment protocol shortly after the treatment is finished.*

I understand that if I fail to use sunscreen, I am more susceptible to sunburn and hyperpigmentation.*

I acknowledge that I have not been on medication for acne therapy during the past 6 months.*

I acknowledge that I have not been using retinoids or any other exfoliating products for the past 3 days and I will discontinue the use of retinoids for 1-3 days after the procedure.*

I acknowledge that facial telangiectasia (small blood vessels) is something more apparentimmediately after the treatment when the skin is thin and will diminish after my skin has recovered from the treatment.*

I agree to remove my contact lenses prior to the procedure (if applicable).*

I have informed my skin care specialist that I am prone to cold sores and I am currently notexperiencing an outbreak. I acknowledge that any area around the mouth or face that is prone to cold sores will be avoided during the treatment (if applicable).*

I understand that the skin care specialist performing the treatment uses tools that are either disinfected or disposable.*

I acknowledge that my skin may experience temporary tightness, mild erythema (redness),or slight swelling, which should dissipate in a few hours following the treatment.*

I understand if I am pregnant, lactating, have rosacea, salicylate/aspirin sensitivity, or an outbreak of any skin condition, I should consult with my physician prior to receiving the DiamondGlow treatment.*

I hereby consent to have the Diamond Glow treatment performed on my skin by a trained operator at Mirage Salon & MedSpa, and to follow all post-treatment protocols.*

I consent to allowing Mirage Salon & MedSpa to use the photographs on their social media for promotional purposes.