HydroPeptide Consultation Consent Form

HydroPeptide Consultation Consent Form
Thank you for your interest in the HydroPeptide Skin Care Collection. Please fill in the requested information to assist your skin care professional in analysing your skin and addressing your concerns. This information will also be used to ensure that you receive the best care possible by making your skin care professional aware of contraindications or medical conditions so that they can choose the targeted treatment best suited to your skin. You may be asked to update this form prior to each visit in order to track changes and progress and ensure that you achieve your skin care goals.
Basic Information
Full Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Phone Number

MobileHome
Occupation
Enter occupation
Do you drink alcohol

NoOther
Do you live with a smoker

NoYes
Do you smoke

NoOther
Medical Information

Do you currently have, or been treated for:

	Yes	No
Acne
Cold sores
Depression
Diabetes
Skin disease
Cancer
High blood pressure
Rosacea (redness)

Have you used any of the following in the past 72 hours:

	Yes	No
Retin-A
Retinol
Benzoyl Peroxide
Chemical peel
Facial waxing
Laser treatment in LAST 4 weeks
OTC Acne treatments
Have you used Accutane within the past year

List any recent resurfacing procedures (including microdermabrasion) or surgeries (including cosmetic)
Enter text
List all medications you are taking
Enter text
List all known allergies
Enter text
List all known health concerns
Enter text

	Yes	No
Are you pregnant or nursing
Are you allergic to aspirin

Skin Care Information

What is your current level of stress

	1	2	3	4	5	6	7	8	9	10

1 is Lowest, 10 is Highest

What is your normal level of stress

	1	2	3	4	5	6	7	8	9	10

1 is Lowest, 10 is Highest

How do you feel about the quality of your skin

	1	2	3	4	5	6	7	8	9	10

1 is Bad, 10 is Good

Do you wear sunscreen*

YesNo
Please list any vitamins or supplements you may be taking
How often do you exercise? Please describe
How much water do you drink daily
When was your last sunburn

MonthDayYear
Date
When in the sun, do you burn:

AlwaysUsuallySometimesRarelyVery RarelyNever
Describe your skin type:

NormalSensitiveDry/ dehydratedNot sureOilyRosaceaAcne/ acne prone

Which skin conditions are you most concerned about?*

	Yes	No
Wrinkles
Dark spots
Dullness
Oiliness
Acne
Acne scarring
Redness
Dry /rough
Other

What are you specifically worried about today?
What is your current skin care routine? Please list product names and regimen
What do you like about your skin?
What don't you like about your skin?

Please read and check acceptance:*

	Check	Uncheck
Prior to receiving treatment, I have been candid in revealing any condition that may be a contraindication to this treatment, such as: Pregnancy or lactating (if so, consult with your physician prior to treatment and avoid products containing salyclylic acid). Recent facial Surgery, allergies, tendency to cold sores/fever blisters, use of topical and/or oral prescription medications such as: tretinoin, retin- a, Lsotretinoin, accutane, differin, tazorac, avage, epiduo or ziana.
I understand that there may be some slight tingling or pin-pricking sensation.
I understand there are no guarantees as to the results of this treatment, due to many variables such as: age, condition of skin, Sun damage, smoking, climate, etc.
I understand I may not actually peel and that such cases depend on the individual.
I understand that the absence of peeling does not Correlate to the amount of improvement.
I understand this is a cosmetic treatment and that no medical claims are expressed or implied.
I understand to achieve maximum results I may need several treatments and regular use of hydropeptide products at home.
I understand though complications are rare, sometimes they may occur. In the event of any complication I will immediately Contact the clinician who performed the treatment.
I understand that extended direct sun exposure is prohibited while I am undergoing treatments, and the daily use of sunscreen Protection with a minimum of spf 30 is mandatory.
I understand that I should follow my clinician's recommendations for post-procedure skin care to minimise side effects and to Maximise results

I hereby agree to all of the above and agree to have this treatment performed on me
Patient Signature*

Clear
Date of Signature*

DayMonthYear
Date of signature
Clinician
Witness
Should be Empty:

HydroPeptide Consultation Consent Form

Basic Information

Medical Information

Skin Care Information