Facial,Dermaplaning,Microdermabrasion Consent Form

FACIAL CONSENT FORM may include: enzymes, acid peels, microdermabrasion, dermaplaning, extractions, and other treatment modalities as necessary.
General Information
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
E-Mail*
Do you have any skin concerns today?:*
If yes, please explain
Medical History
Please list any allergies*
AlgaeAnimalsAspirinCosmeticsDairyEssential OilsFoodLatexMedicineNiacinNutsSalicylic AcidShellfishSulferSunscreenNone
AnemiaAny Active InfectionsAsthmaArthritisBlood clotting disordersCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackHerpesHepatitisHIV/AIDSRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseKidney DiseaseLiver DiseaseSleep ApneaSkin CancerUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaKeloid ScarringSkin Disease/Skin LesionsMetal bone Pins, Plates or PacemakerNone
Other illnesses:
Please list any Surgeries, including plastic surgery
Please list your Current Oral & Topical Medications *
Are you Pregnant or Nursing?
If Pregnant, how many weeks ?
YesNo
YesNo
Have you had Botox or Dermal Fillers*
Blackheads/ WhiteheadsBreakouts/AcneBroken CapillariesCongestionDeep WrinkesFine linesDiscolorationDull/ DrynessOily skinOther
Healthy & Unhealthy Habits
YesNo
YesNo
YesNo
I don't drink1-2 glasses/week3-4 glasses/week5+ glasses/week
YesNo
Please list any skincare products that you are currently using:
1. I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, microdermabrasion, dermaplaning, extractions, and other treatment modalities as necessary.2. I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.3. I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.4. I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness5. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact a member of the Sweetys skincare and lashes staff.6. I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory.7. I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior.9. PHOTOGRAPHS: I give permission for photographs to be used by the Sweety’s Skincare and Lashes staff for monitoring my treatment progress.10. Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Sweety’s Skincare and Lashes of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.11. I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release Sweetys Skincare and Lashes and any of its employees against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.12. By my electronic signature below, I give consent to receive treatments at Sweetys skincare and Lashes and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or Sweetys skincare and lashes for any services rendered.
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

General Information

Medical History

Healthy & Unhealthy Habits