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Glow Dermspa Consent Form

Before you proceed with any specific treatment at Glow Dermspa, it’s crucial for us to ensure you fully understand and consent to the procedure. We’ve provided detailed consent forms for each individual treatment to give you an in-depth understanding of the procedure, its potential risks, benefits, and post-treatment care. Please review the relevant consent form for your chosen treatment by clicking on the links below:

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Financial Agreement*
I agree that I am financially responsible for the full payment of service provided. Payment is expected at the time of service. I understand these services are non-refundable and that insurance never covers cosmetic procedures. All other fees are calculated on the actual amount of product used to achieve the desired effect. I also understand that there will be an additional fee for touch ups.
Cancellation / No Show Policy*
A 48-hour notice is required for any appointment changes or cancellations. A cancellation fee of $100 will be charged for any no shows and for any changes or cancellations made within 48 hours of the appointment day and time on the credit card on file.
Service Package Policy*
To deliver the best level of patient care and outcomes, some of our treatments are best utilized in a series for optimal outcomes and results. To encourage patients to complete the necessary number of treatments for optimal results, we offer treatment packages at a discounted rate to help deliver the highest level of care. We strive for transparency and for clear expectations to be set with the policies below:
  • All service packages and prepaid treatments must be within one year from the date of purchase or they will expire.
  • All service packages and prepaid treatments are considered “final sale” and are non-transferable and non-refundable.
Refund Policy*
We do not offer refunds on any services rendered. Aesthetic results are quite variable from person to person and while we do our best to achieve the desired outcome, it cannot be guaranteed. Clients are responsible for additional treatments needed to achieve desired results.
Privacy Acknowledgement:*
We are required to protect your privacy. Our Notice of Privacy Policy (NPP) details your rights as a patient and how we may use and/or disclose your protected health information.
Pre/Post Care Instructions*
Preparing for treatment and being able to perform post-care (if any) is important to obtain optimum results. I will review the pre and post-care instructions for my treatment, which are available through the link provided here.
Informed Consent*
Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post-treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history, I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment/results I will notify this office at immediately so that timely follow-up and intervention can be provided.
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