Sacred Skin Nano-Facial Client Intake and Consent Form: (Required only for clients receiving Nano-Facial treatments)

Sacred Skin Nano-Facial

CLIENT INTAKE & CONSENT FORM
Date:

MonthDayYear
Date
CONTACT INFORMATION
Name:
Birth Date:

MonthDayYear
Date
Address:
City:
State:
Zip:
Cell Phone:
Work Phone:
E-Mail Address:
example@example.com
Emergency Contact: Name & Phone
Primary Physician:
Do we have permission to contact you by phone or leave messages?:
No

Do we have permission to contact you by phone or leave messages:Yes
Text

Preferred method of contact:PhoneE-Mail
No

Do we have permission to show your photos for educational purposes?Yes
CONCERNS
What concerns you most about the overall appearance of your skin? (check all that apply)

AcneDehydrated SkinOily SkinAcne ScarringDull ComplexionRednessAge SpotsExcessive Facial HairRough/Uneven Skin TextureBlackheadsFacial VeinsRosaceaBody AcneFine Lines/WrinklesSagging SkinBroken Blood VesselsFrequent BreakoutsSun DamageBumps on back of armsLarge PoresUnder Eye Puffiness/Dark CirclesCelluliteLoss of Lashes/BrowsCysts/NodulesMelasma/Brown Spots/PatchesUnder Eye Puffiness/Dark CirclesOther
How would you describe your skin?

OilyDryCombinationSensitive
How would you describe your stress level?

LittleModerateHighSevere
Do you feel your stress level may be affecting the health of your skin?

NoYes
Are you in good health overall?

YesNo
Concerns:
HISTORY
Are you currently under the care of a physician?

YesNo
Explain If Yes:
Do you have any allergies to foods or medications?

YesNo
Explain If Yes:
Are you currently on any medications either topical or oral?

YesNo
If yes, please list:
Ethnic Background (Parents, Grandparents and Great Grandparents):
How do you heal after an acne breakout, cut or scratch?

No scarRedBrown (PIH)
Do You Smoke?

YesNo
Are you prone to cold sores?

YesNo
No If yes, date of last cold sore?

MonthDayYear
Date
Do you have an allergy to Latex?

YesNo
Do you tan in the sun or in tanning beds/booths?

YesNo
Please check the skincare products you are currently using:

CleanserTonerSerumScrubMaskEye CreamMoisturizerSunscreenSelf TannerConcealerMakeupOtherOther
Anything else we should know:
DESCRIPTION OF THE FACIAL:
The Rezenerate Facial System allows the targeted products/serums chosen by you and your skin care professional to reach maximum efficacy! The intended result is typically smoother, firmer and younger looking skin, but any number of results can be achieved depending upon the chosen serum/products used. Rezenerate Facials are performed in a safe and precise manner with the use of sterile Rezenerate components. (All serum/products should be discussed separately with your skin care professional
POTENTIAL SIDE EFFECTS:
I recognize there are no guaranteed results and that results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further facials to obtain the expected results at an additional cost. After the Facial, in rare cases, the skin will be pink and flushed in appearance. You may also experience skin tightness and mild sensitivity to touch or sweating on the facial area.
CONTRAINDICATIONS:
Contraindications include: Keloid scars; active inflammatory conditions; history of actinic (solar) keratosis; history of active Herpes Simplex infections; history of diabetes; presence of raised moles, warts on targeted area; scleroderma, collagen vascular diseases; blood clotting problems; active bacterial or fungal infection; immuno-suppression. Not recommended for women who are pregnant or nursing.
CLIENT CONSENT:
I understand that results will vary between individuals. I understand that although I may see a change after my first Rezenerate Facial; I may require a series of Rezenerate Facials to obtain my desired outcome. I understand that the Rezenerate Facial is a cosmetic treatment, not a medical procedure. The Rezenerate Facial and any potential contraindications or side effects have been explained to me to my complete satisfaction. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success, or any other result of the Rezenerate Facial, and I hold Rezenerate and my skin care professional harmless for any undesired effect. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the Rezenerate Facial including risks or alternatives and acknowledge that all my questions about the facial have been answered in a satisfactory manner.

THIS CONSENT FORM SHALL BE VALID FOR ALL REZENERATE FACIALS I RECEIVE.
Print Name:
Signature:
Signature

Clear
Date:

MonthDayYear
Date
Should be Empty:

Sacred Skin Nano-Facial

CONTACT INFORMATION

CONCERNS

HISTORY

DESCRIPTION OF THE FACIAL:

POTENTIAL SIDE EFFECTS:

CONTRAINDICATIONS:

CLIENT CONSENT:

Signature: