At AAC our focus is to create a customized client experience in order to help you achieve your skin care and anti-aging goals. This questionnaire helps us decipher your needs and allows us to better guide you on your journey to your best self!
Have you ever had any of the following?
I full name* authorize Safelase Institute of Connecticut LLC dba Anti-Aging Centers of Connecticut and it's designated staff to perform Skin Rejuvenation treatments on me. I have been advised of pre-post treatment procedures and possible adverse reactions which are as follows:
If skin experiences an excessive reaction, cool the treatment area immediately after treatment. Be sure to have cool packs (not frozen) or cold, wet towels.
I understand that the specific device used is a device used for skin rejuvenation, acne treatment, wrinkle reduction, skin resurfacing, facial vessels, leg veins and/or other vascular lesion treatments, of which I am consenting to be a patient receiving treatment. I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre-and post-treatment instructions, and individual response to treatment. I understand that there is a possibility of short-term effects such as reddening, mild burning, temporary bruising and temporary discoloration of the skin, as well as the possibility of rare side effects such as scarring and permanent discoloration.
These effects have been fully explained to me. full name* I understand that Skin Rejuvenation treatments involve a series of treatments and the fee structure has been fully explained to me. client initials* .
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm tohat I have informed the staff regarding any current or past medical condition, disease or medication taken. I consent to the taking of photographs and authorize their anonymous use for the purposes of medical audit, education and promotion. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form. I consent to the taking of photographs for the purpose of medical education. I understand that my identity will not be revealed in the photographs or corresponding text.
By signing below, I acknowledge that I have read and understand all information presented to me before signing this consent form. I hereby release Safelase Institute of Connecticut LLC dba Anti-Aging Centers of Connecticut, its medical staff and technicians from any liability arising out of the services associated with the above treatment.
I have received a copy of the Consent & Client Instructions
As part of your treatment, we will be photographing the treatment area of your body/face (and in some cases, filming the treatment process). This will allow us to visually monitor your individual progress and see the results of your treatment over time. We would appreciate your willingness to share your outcomes and results with others, for both training and marketing purposes within the beauty, cosmetic and aesthetic industry. Your identity/personal information will not be revealed, if not preferred.
With this form I, First Name* Last Name* give my full consent for all photographs/footage captured before, during, and after my treatment at Anti-Aging Centers of Connecticut to be used for the following purpose (please initial the consent area below for each specified use):
I fully understand and agree to this consent form. I understand and agree that all photos will become the property of Anti-Aging Centers of Connecticut and will not be returned. I hereby irrevocably authorize the Anti-Aging Centers of Connecticut to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge the Anti-Aging Centers of Connecticut from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I have read and understand the above photo release. I affirm that I am at least 18 years of age, or if I am under 18 years of age, I have obtained the required consent of my parent/guardian as evident by their signature below:
We understand emergencies happen, and you may not always be able to call in advance. However, please know that when you 'no show' or cancel an appointment within 24 hours, you are preventing other clients from receiving their services. In addition, our technician is left without a client to serve, and when this happens frequently, it hurts our whole AAC family.
If you need to adjust, reschedule or cancel your appointment, please call and leave us a voicemail if you do not speak directly with a staff member. This way, we will be able to continually adjust our schedule to best accommodate our clients, and we will have a record that you called outside of the 24 hour timeframe. We will always get back to you once we receive your message.
In the event that you 'no show' or cancel your appointment within 24 hours, we will charge the credit card on file a 'no show' fee in the amount of $25.00 if the appointment is scheduled for less than 60 minutes. If the appointment is scheduled for 60 minutes or more, you will be charged a $75.00 'no show' fee. If the credit card on file declines, the 'no show' fee will be added to your account with us, and you will owe the amount to be paid in full at your next scheduled appointment.
AAC is an in-demand, busy medical spa. Please note that canceling or rescheduling appointments with short notice may result in longer waiting times for appointments, and AAC cannot guarantee you will be able to stay on your recommended treatment plan schedule.
At AAC, we do require that a credit card or debit card is kept on file as a convenient method of payment, in the event of a "no show' or late cancellation (within 24 hours of scheduled appointment time). Our credit card information is kept confidential and secure.
By signing below, I authorize AAC (Anti-Aging Centers of CT) to charge a no show fee to my credit or debit card on file, in accordance with all of the above information if I "no show' or cancel an appointment within 24 hours. I, the undersigned, recognize that it is my financial responsibility to pay any incurring fees in accordance with this policy.