Consultation Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What treatment are you having today?

Within the last year, have you had any health problems that have affected or could affect your skin?

YesNo

List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly.

Do you wear contact lenses?

YesNo

Do you have metal implants, a pacemaker or body piercings?

YesNo

Do you have any allergies? If yes, please specify:

Do you have sinus problems?

YesNo

Have you ever experienced claustrophobia?

YesNo

What are your specific concerns/challenges with your skin?

What skin care products are you currently using?

Have you had chemical peels, microdermabrasion, or any other resurfacing treatments in the last two weeks?

yesno

Have you been waxed in the last 1-2 weeks?

yesno

Have you used Retin-A, Revona, Adapalene or any other prescription skin products within the last three months?

yesno

Are you currently using any products that contain the following ingredients? If yes, which ones?

Please specify if any of the following apply to you:

Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?

yesno

Do you have active cold sores?

yesno

Have you received Botox within the past 2 weeks or other injectable procedures within the past 4 weeks?

yesno

Do you sunbathe or use tanning beds?

yesno

Do you experience redness, itching or flaking on your skin?

yesno

Further Comments

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome.

The procedure contraindications, precautions and warnings have been explained to me including alternative methods, as have the advantages and disadvantages.

I am advised that though good results are expected, the possibility and nature of complications cannot be fully anticipated.

Therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that the results of this treatment with Dermalogica are not permanent as natural degradation will occur over time.

I have read this consent form and I understand the information contained in it.

I have had the opportunity to ask any questions about the treatment, including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner.

THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME IN WRITING.

I release and waive any claims against Dermalogica, LLC and My Store subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the this treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and/or My Store.

I certify that the information I have provided on this form is accurate, to the best of my knowledge, and that I have not withheld any information that will be relevant to my consultation.

Date*

Date

Signature*