ADS Evaluation Form

SKIN TREATMENT: Informed Consent Form

Allana Davis Studio
Personal Information
Todays Date

MonthDayYear
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*

Area CodePhone Number
E-mail*
Referred by (who can we thank for sending you?)
Emergency Contact*
Emergency Contact Phone Number*
What are your skin concerns? (Wrinkles, pigmentation, melasma, anti-aging etc)
Do you use Retinol, Retin-A or Renova or any other chemical or physical exfoliant? (Please discontinue use off these products 1 week before your treatment)*

YesNo
Brand, Type, How Often*
Do You Have A Reaction To Vitamin C? (Allergic, Inflamed, Painful, Skin Sensitivity, etc)

YesNo
Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months
Medical Information:
Are you allergic to shellfish or any medications or products?*

YesNo
If yes please explain:
Have you taken Accutane for acne in the past three months:

YesNo
Have you seen a dermatologist in the past five years?

YesNo
Do you have Dermatitis, Eczema, Seborrhea, or Rosacea?

YesNo
Where & What triggers your flushing?
Are there any medical problems we should be aware of (HIV, AIDS)?

YesNo
If so, please list
Do you have claustrophobia (for treatments that cover clients eyes and mouth)*

YesNo
List current medications or vitamins you are presently taking and reasons
Your Skin Type
Do you have problems with healing or scarring?
Are you light sensitive?
Have you experienced any recent changes in hair color or thickness?
Check All That Apply

AcneBlood ThinnersCanker SoresCold SoresDo you smokeDo you have hormonal imbalance (hormonal acne)DiabetesEpilepsy/SeizuresHeart ConditionHemophiliaHigh Blood PressureIodine (allergies (Repêchage facial))Keloidq ScarsLatex AllergiesMolesMiliaPacemakerUse Alpha Hydroxy (AHA)Use Benzyl PeroxideUse Glycolic AcidsUse Oral Or Topical Antibiotics
Female Specific Information
Check All That Apply:

Breast FeedingEndocrine ProblemsMenopause (If post say yes)PregnantRegular PeriodsOn Birth Control
Tanning or Sun Exposure
Check All That Apply

SunbathingTanning BookSpray Tan/Tanning Lotions
Have you recently vacationed or are you planning a vacation with sun exposure?

YesNo
When
Do you have any existing skin conditions

ScaringPigmentation problems (dark or light patches)RashTelangiectasiaTattooPermanent make-upImplantsAge Spots
What is your skin complexion?

LightMediumOliveDark
Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skin
Are You Having Milia Removal?

Yes (read consent below)No
Milia Remival Consent: By proceeding with our Milia removal treatment, you acknowledge and accept the risks associated with this procedure. This treatment involves the use of a sterile lancet needle to gently extract Milia, which are small, keratin-filled cysts typically found on the skin. While we adhere to the highest standards of care and hygiene, as with any skin treatment, there is a risk of side effects, including but not limited to scarring, pigmentation changes, or infection. By signing this form, you agree not to hold [Your Business Name] or its practitioners liable for any such outcomes. We are committed to providing you with a safe and effective treatment and will discuss any concerns you may have prior to the procedure.
By signing below, I acknowledge and consent to the following statements:

I acknowledge that temporary skin irritation, breakout, tightness, redness, or slight swelling may occur after the treatment, which usually dissipates within 72 hours depending on my skin sensitivity.

I acknowledge that if I have any allergies to the products used, I may experience allergic reactions.

I acknowledge that failure to use a minimal SPF 30 sunscreen may result in sunburn, skin damage, and hyperpigmentation, and I should avoid excessive sun exposure, especially between 10am-2pm.

I acknowledge that this treatment is strictly an elective cosmetic procedure, and no medical claims have been expressed or implied.

I acknowledge that I should avoid using Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following the treatment unless discussed with my aesthetician at Allana Davis Studio (operated by MakeupLady Canada).

I acknowledge that I have informed my esthetician of any medical conditions, allergies, or medications that could increase the risk of complications during or after the treatment.

I acknowledge that I have been provided with a detailed description of the facial/microneedling procedure that will be performed, including the equipment and products that will be used, the length of the treatment, and any post-treatment instructions.

I acknowledge that there are risks associated with this facial/microneedling treatment, and I assume all responsibility for any complications that may arise. I release Allana Davis Studio (operated by MakeupLady Canada) and its staff from any liability, claims, damages, or expenses that may result from the treatment.

I give consent to the best of my knowledge that the answers I have provided are correct and that I have not withheld any relevant information for my treatment. I also give consent for all future treatments.

I acknowledge that [your business name] carries insurance coverage for this facial/microneedling treatment and that this consent form meets the insurance provider's requirements.

Cancellation Policy:

At the Allana Davis Studio (operated by MakeupLady Canada), we highly value your appointments and consider them a top priority. We reserve your appointment slot exclusively for you and understand that schedule changes may become necessary. We kindly ask that you provide us with a minimum of 24 hours' notice for any cancellations.

For appointments cancelled less than 24 hours in advance, a charge equivalent to 100% of the original appointment cost will be applied to your credit card on file or billed at your next appointment. For same-day cancellations, the full cost of the original appointment will be charged to your credit card on file or billed at your next appointment. We appreciate your understanding and cooperation.
What do you want to improve most about your skin?*
I have read and understood the information provided in this consent form, and I agree to the terms and conditions.
Date*

MonthDayYear
Date
Signature*

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SKIN TREATMENT: Informed Consent Form

Medical Information:

Female Specific Information