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E-lux Radio-frequency Consent Form

E-Lux Radio Frequency Consent Form

A gentle, pain-free treatment that deeply cleanses, hydrates, and revitalises your skin using advanced jet-infused saline and oxygen, leaving it smooth, fresh, and glowing.

Full Name * Date of Birth * Email Address * Phone *

I understand that I will be undergoing Radio Frequency treatment and certify that:

I am not pregnant or nursing. I am over 18 years of age. I do not have a pacemaker, internal defibrillator, or metal implants in the treatment area. I do not have current or a history of cancer, especially skin cancer, or pre-malignant moles in the area of treatment. I do not have an impaired immune system due to immunosuppressive diseases such as AIDS, HIV, or the use of immunosuppressive medications. I do not have any severe concurrent conditions such as cardiac disorders. I do not have a history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area. If applicable, I agree to use prophylactic antiviral therapy. I do not have any active condition in the treatment area, such as sores, psoriasis, eczema, rash, or excessively/freshly tanned skin. I do not have a history of skin disorders such as keloid scarring, abnormal wound healing, or very dry and fragile skin. I have not had any surgical, invasive, or ablative procedure in the treatment area before treatment. I do not have any medical condition that might impair skin healing. I do not have any permanent implant in the treated area such as metal plates, screws, silicone implants, or injected chemical substances. I do not have any poorly controlled endocrine disorders, such as diabetes. I have not used Isotretinoin (Accutane) within the last 6 months. I understand that this treatment is not guaranteed to achieve the results that I want and there is no way to predict the response that I will get. I understand that it may take 6–12 months to see maximum benefits and that results may be reduced or eliminated by weight fluctuations and the normal ageing process.

Therapist Name Electronic Signature *

Date *

Glemz Hair & Beauty Studio - Appointment Booking Request

Glemz Hair & Beauty Studio - Choose your service and preferred time. Our team will review and confirm your booking shortly.

First Name

Last Name

Email Address

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What would you like to book?

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Preferred Date

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Additional Request / Notes

I understand that submitting this form is an appointment request only. My appointment is confirmed only after Glemz Hair & Beauty Studio confirms the date and time.

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E-lux Radio-frequency Consent Form

E-Lux Radio Frequency Consent Form

I understand that I will be undergoing Radio Frequency treatment and certify that:

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