Faith Aesthetics Informed Client Consent: Radio Frequency/High Frequency

Informed Client Consent: Radio Frequency/High Frequency
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
What is your ethnicity?*

CaucasianBlack/African AmericanAsianLatinxNative AmericanOther
How would you describe your skin?*

NormalOilyDryCombination
When was your last prolonged sun exposure (including tanning beds)?*
Have you ever had treatments for vascular veins, pigmented lesions, or other unwanted lesions?*

YesNo
If yes, please indicate when, what area of the body and describe you experience:
Have you used Accutane in the past year?*

YesNo
Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, antiaging or hyperpigmentation?*

YesNo
If yes, please list:
Have you ever had any of the following injectables or implants?*

BotoxJuvedermRadiesseRestylanePerlaneSiliconeCollagenSculptraDysportNoneOther
If yes, when and what body areas?
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?*

YesNo
If yes, please explain:
Do you form thick or raised scars from cuts or burns?*

YesNo
Have you had chemotherapy in the past 6 months?*

YesNo
Do you have any allergies to medications, food, latex, topical products, and/or other substances? *
Do you have any of the following conditions?*

EpilepsyPregnancy and/or breastfeedingAutoimmune diseaseHerpes SimplexDiabetesDental implants, crowns, metal fillingsPacemaker or internal defibrillatorVaricose veinsHistory of skin disordersMetal implants or other implants in the treatment area, i.e., IUD, screws, platesImplanted neuro stimulators or other internal electric deviceNone
Do you have a history of Erythema Ab Igne (EAI), a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?*

YesNo
Do you have any other health condition not mentioned here?*

YesNo
If yes, please explain:
Have you consumed drugs or alcohol in the last 24 hours?*

YesNo
Have you undergone any recent surgery?*

YesNo
If yes, please explain:
Please list all vitamins and supplements including herbal remedies you take regularly:*
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly:*
Is there anything else you would like us to know?
By signing below, I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the aesthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures.
Signature - Use a mouse or your finger to enter you signature.*

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Please verify that you are human*
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