Fire & Ice Consent Form
Please fill out and answer all questions accurately and honestly, failing to do so may result in reactivity during treatment, or not being able to perform treatment upon arrival at studio.
Name
First Name
Last Name
Birthday
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
example@example.com
Have you submitted your COVID-19 pre-screening form? If not, please fill it out now before continuing with this form submission. No clients will be admitted who have not submitted their pre-screening form prior to their booking. You'll find the link in your appointment confirmation email.
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Yes
Have you used prescription-grade topicals (ex. Retin-A, Renova, Tretinoin, Differin, Benzoyl Peroxide, Hydroquinone, Retion/Vitamin A derivatives etc.) within last 7 days?
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Yes
No
Have you done any of the following forms of hair removal in the last 7 days (waxing, sugaring, threading, or depilatory cream)?
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Yes
No
Have you experienced extended sun exposure in the last 10 days that has resulted in a sunburn, redness, peeling or skin sensitivity?
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Yes
No
Have you received cosmetic injectibles in the last 14 days, including but not limited to Botox and dermal fillers?
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Yes
No
Have you experienced any form of aggressive exfoliation, professional-grade skincare treatment, resurfacing treatment, micro-needling (including at-home dermarolling) in the last 14 days?
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Yes
No
Have you had microblading, powdering, or any form of permanent makeup applied in the last 8 weeks?
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Yes
No
Have you had any surgery to the treatment area (including cosmetic and non-cosmetic) in the last 8 weeks?
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Yes
No
Have you been on Accutane (or any other form of oral acne medication) within the last 6 months?
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Yes
No
Do any of the following apply to you?
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Acne-Prone
Active Eczema / Dermatitis / Psoraisis
Active Cold Sore(s)
Asthma
Blood Thinners (or history of bleeding problems causing delayed coagulation)
Breastfeeding
Cancer Therapy (Chemotherapy / Radiation)
Claustrophobic
Epilepsy / Prone to Seizures
Facial Threads / Thread Lift
Hepatitis
Heart Condition
HIV/AIDS
Hormonal Imbalance
Metal Implants
Menopause
Rosacea
Pacemaker / Internal Defibrillator
PCOS
Pregnant
Uncontrolled Disbetes
Uncontrolled Thyroid Condition
Wear Contacts
None of the above
Other
Please list any allergies you have.
Have there been changes to your medical history since submitting your initial Skin Consult Form which I should be aware of? Including, but not limited to, changes to medical history, prescription medications and topicals, skin reactions, or new skin conditions?
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Yes
No
If yes, please let me know what changes there have been?
Please select the add-on(s) you've booked along with this treatment?
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Radio Frequency w/ Celltense
LED Light Therapy
O2 Dome (Oxygen Therapy)
HA + GF Growth Factor
Extra Blackhead Relief
None
FIRE & ICE CONSENT & ACKNOWLEDGEMENT: This resurfacing treatment is safe for all skin types and provides the power of a glycolic acid peel within a kaolin clay based masque. Some patients may experience slight discomfort. It is usually minimal and lasts for only a short period of time. Very infrequently a patient may experience some slight redness and swelling. If this occurs, it is generally minimal and will subside after a few hours to a few days. Demarcation may occur, referring to the difference in color, texture, or pigmentation that may occur at the junction between the treated and non-treated skin areas. Existing blemishes, moles, blood vessels (telangiectasias), freckles and sunspots may become more obvious or appear to be darker since layers of dead skin have been removed. Scarring is very unusual but may occur. Pigmentation, although extremely rare, temporary and possibly permanent changes in the color of the skin may occur. Milia may occur but will usually disappear quickly. Infection is extremely unlikely but may occur. Individuals with the pre-existing condition of herpes simplex virus can become more prone to an outbreak. If chemicals get into the eye, scarring and vision disturbances may occur. The above list is not intended to be a complete list of all possible complications. Please be aware this treatment also includes High Frequency. This technology functions by using a glass high-frequency electrode. When applied to the surface of the skin, a mild electrical current passes through the neon, or argon gas-filled glass electrode, causing it to emit a subtle glow and buzzing noise. Depending on the inert gas that they are filled with, the electrodes produce either a neon red/orange or violet/blue light. It is imperative that you inform your practitioner if you are pregnant or have a pacemaker as these are STRICT contraindications to treatment. I understand that I may require additional treatments in order to achieve maximum results. I have been advised that the object of the procedure I have requested is improvement in appearance, not perfection. It is possible for imperfections to persist, and that the result might not live up to my expectations or goals. I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made. Please understand that you may require additional treatments in order to achieve maximum results. Understand that the object of the procedure requested is an improvement in appearance, not perfection. It is possible for imperfections to persist, and that the result might not live up to your expectations or goals. Understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.
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I Agree
ROOM ONE RELEASE & ACKNOWLEDGEMENT: I hereby consent to and authorize Room One and my service provider to perform the requested treatment outlined in this consent. I have completed this form to the best of my ability and acknowledge and agree to inform my service provider of any changes in the above information which may cause me to no longer be a candidate for this treatment. I have also, to the best of my knowledge, given an accurate answers to all questions in this consent. I have voluntarily elected to undergo this treatment after the nature and purpose of this service has been explained to me, along with possible risks and complications, and I understand it is impossible to list every potential risk and complication. I understand the treatment and accept the risks outlined tome above. I understand it is my responsibility to consult my physician if I am uncertain if I should receive this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon, but not limited to age, skin conditions, lifestyle and skincare. Please understand that you may require additional treatments in order to achieve maximum results.Understand that the object of the procedure requested is an improvement in appearance, not perfection. It is possible for imperfections to persist, and that the result might not live up to my expectations or goals. Understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made. I will inform the service provider of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I understand that it is my responsibility to follow the advice and direction of my service provider during the treatment and post-care advice (if any) provided to me. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I understand that Room One and its employees, clients or anyone affiliated with Room One is not responsible for any misplaced, lost or stolen items which I bring to Room One. Should any valuable or personal items go missing, I cannot blame or request a replacement or compensation of any kind be given to me by Room One. I understand it is my responsibility to arrive to my scheduled appointment on-time, and that lateness whether intentional or unintentional may result in a shortened treatment, or possibly a forfeited treatment. Forfeited treatments are considered No Shows. No Shows are the result of intentionally or unintentionally missing your appointment. Forfeited Appointments/No Shows result in a fee of $130 being charged to your credit card on file. I also understand that Room One adheres to a strict Cancellation Policy, which requires me to cancel my appointment 48-hours before my scheduled appointment time. Failing to do so will result in a Cancellation Fee of $75 being charged to my credit card on file. I release, discharge, hold harmless, and absolve Room One, its affiliates, members, subsidiaries ,employees, directors, officers and agents (the "Released Parties" )from any and all actions, costs and expenses (including attorney's fees), suits, demands of any kind whatsoever,and claims of liability of any nature, including claims of active or passive negligence, for any damages or injuries, which I, my heirs, executors,administrators and assigns may actually suffer or incur by reason of any matter connected in any way with the Services. By signing this consent, I understand that I am giving up my right to sue the Released Parties for any claims,damages or injuries relating to the services I receive. I understand that I should not have the services if I have ANY contraindications, which will be determined by Room One based on the answers I’ve provided in this consent. I have read and fully understand this agreement and all information detailed above.
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I Agree
Client Signature
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Treatment Date
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