Sample Esthetician Consent Form

For reference use only. May not be legal in your jurisdiction.

Microcurrent Therapy Consent Form

Client Information:

Name: ______________________________
Date of Birth: _______________________
Address: ___________________________
Phone: ____________________________
Email: ____________________________

Session Details: I, the undersigned, consent to receive microcurrent therapy sessions performed by a licensed esthetician in accordance with the terms outlined in this consent form. This consent covers any number of microcurrent sessions performed within six (6) months from the start date indicated below.

Start Date: _______________________

What is Microcurrent Therapy? Microcurrent therapy is a non-invasive treatment using low-level electrical currents to stimulate facial muscles, improve skin tone, and promote collagen production for a rejuvenated appearance.

Potential Benefits:

Enhanced facial toning and lifting
Improved skin texture and elasticity
Reduced appearance of fine lines and wrinkles

Possible Risks and Side Effects: While microcurrent therapy is generally considered safe, potential side effects may include:

Temporary redness or tingling
Minor skin irritation
Muscle twitching during the session

Contraindications: Microcurrent therapy is not suitable for individuals with the following conditions:

Pacemaker or other implanted electronic devices
Pregnancy
Epilepsy or seizure disorders
Active cancer or undergoing chemotherapy
Heart conditions
Metal implants in the treatment area
Open wounds or active skin infections in the treatment area
Recent surgery or Botox/filler treatments within two weeks

Client Acknowledgment and Consent: I understand that:

Microcurrent therapy is a cosmetic treatment and not a medical procedure.
Results may vary, and no guarantees are made regarding the outcome.
I will inform the esthetician of any changes in my health status or medications.
This consent remains valid for six (6) months from the start date listed above.

I have read and understood the above information. My questions regarding the procedure have been answered to my satisfaction. I understand the risks and benefits and consent to receive microcurrent therapy sessions.

Client Signature: ____________________________
Date: ____________________________

Esthetician Signature: ____________________________
Date: ____________________________