Client Details

Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

Consent Version

Consent Version: ELURENA-CONSENT-IONIC-RADIANCE-V1.0-2026

About the Treatment Heading

ELURENA – IONIC RADIANCE TREATMENT CONSENT & LIABILITY FORM

About the Treatment Text

Elurena Ionic Radiance is a non-invasive skin rejuvenation treatment that uses ionic energy and gentle electrical currents to enhance skin clarity, hydration, and radiance. Results vary from person to person.

What to Expect

During or after Ionic Radiance treatment, you may experience:

Mild tingling, warmth, or light vibration during treatment.Temporary redness, mild swelling, or sensitivity may occur.Skin may appear brighter immediately, with continued improvement over multiple sessions.Rare risks may include minor irritation, allergic reaction, or uneven results.No refunds are offered for treatments.

Ionic Radiance Contraindications

Do you have a pacemaker or implanted electronic device? *

Yes No

Do you have epilepsy or a seizure disorder? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have active skin conditions such as eczema, dermatitis, psoriasis, or infections in the treatment area? *

Yes No

Do you have metal implants in or near the treatment area? *

Yes No

Have you had recent cosmetic treatments such as laser, chemical peel, or injectables? *

Yes No

Do you have a history of keloid scarring or poor wound healing? *

Yes No

Do you have uncontrolled diabetes or bleeding disorders? *

Yes No

General Medical Declaration

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

Ionic Radiance Consent Confirmation

Ionic Radiance Consent Confirmation *

I understand the Ionic Radiance treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with Ionic Radiance treatment.

Optional Photography Consent

Photography Consent Text

I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

Final Treatment Agreement

Treatment Information Confirmation *

I confirm that I have read and understood the Ionic Radiance treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of Ionic Radiance treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with Ionic Radiance treatment.

Signature

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – Ionic Radiance Treatment Consent Form

Client Details

ELURENA – IONIC RADIANCE TREATMENT CONSENT & LIABILITY FORM

What to Expect

Ionic Radiance Contraindications

General Medical Declaration

Ionic Radiance Consent Confirmation

Optional Photography Consent

Final Treatment Agreement

Signature