SEAWEED PEEL CONSENT FORM

SEAWEED PEEL CONSENT FORM

Thank you for choosing EN Signature Brow and Beauty studio for your services. We love to give every client the best quality service. Please fill out the form below.
This form is designed to provide information for making an informed decision regarding your peel. If you have any questions, please do not hesitate to ask your esthetician. While peels are effective in most cases, no guarantee can be made for individual results.
Name:*

First NameLast Name
Occupation:
Sex:*
Age:*
Email:*
example@example.com
Phone Number:
Please enter a valid phone number.
Skin tone

Pale/WhiteLight Redish/FrecklesLt.OliveMed.OliveDark OliveDark Brown
Eye Color
Hair Color
Do you wear contacts?
Do you have permanent makeup? If so, where?
Have you had a peel before?
Describe your skin choose all the apply:

NormalOilyDryT-zone/CombinationFreckledSun DamagedUneven/BlotchyMatureWrinkledSaggyLargeporesSmall poresAcneMiliaComedomesOccasional BreakoutsScarredCystic MelasmaRosaceaHypo-pigmented or Hyper-pigmented
Do you consider your skin Sensitive or Tolerant?
Do you have dilated capillaries or spider veins on your face?

YesNo
Are you sun or wind-burned?

YesNo
When was the last time you tanned?
When was the last time you had facial hair removed?
Are you pregnant?

YesNo
Trying to get pregnant?

YesNo
Have you had an “injectable” treatment from a Physician recently?

YesNo
If "Yes", When?
Are you recently facially post operative?

YesNo
If "Yes", When?
Are you allergic to milk, apples, citrus, grapes, aloe vera, aspirin or hydraquinone?

YesNo
Any other allergies?
Are you using any of the following:

Retin ARenovaAccutane
How frequently?
Are you taking hormones, birth control?

YesNo
What kind?
Please list all medications (prescription and OTC)
Have you ever had an adverse product reaction?

YesNo
Describe
Do you smoke?

YesNo
Do you drink caffeine?

YesNo
How Much?
Do you drink Alcohol?

YesNo
Do you get cold sores/ blisters?

YesNo
Do you take medication for cold sores/ blisters?

YesNo
What is your skin care regime?
What about your skin bothers you and what would you like to have corrected or improved?
Check and Agree with the following:*

I have completed the client profile/medical history form accurately.I have been can did in revealing any condition that could prohibit this treatment such as cold sores, pregnancy, and the use of hormones, recent facial surgery, laser resurfacing or injectable treatments, recent use of Retin-A, or use of Accutane in the last 12 months.I understand that there are no guaranteed results from this treatment. Many variables such as age, sun damage, on going sun exposure, smoking, excessive alcohol intake, climate, diet, and water intake, skin thickness, and sensitivity can affect results. I understand that I may or may not peel and that each case is individual.Regardless of precautions taken, I acknowledge the possibility ofan adverse reaction to the peel and accept sole responsibility for any medical care that may become necessary. I will immediately contact the Esthetician that is performing the treatment of any adverse reactions.I will not scratch, pick, pull at or abrade the treated skin.I understand that direct sun exposure and the use of a tanning booth is prohibited during this treatment time, and that a mandatory use of a minimum SPF 30 mineral based sun protection daily is requiredI understand that to achieve maximum results I must follow the recommended home care regimen outlined by my esthetician. Altering the regimen or using products other than those recommended may alter or inhibit results. For Timeless Peel use of the After Care Kit is required.I understand that it may take several treatments to obtain the desired results.I understand that the following side effects or complication scan occur: 1.Discomfort 2. Redness and swelling 3. Hypo-pigmentation 4. Itching or irritation 5. Infection 6. Scarring 7. Hyper-pigmentation 8. Acne breakouts 9. Skin peeling or flaking up to 14 days after the procedure.I understand the goals of the treatment as well as the limitations and possible complications.
I am 18 years old or older

Yes, I am 18 years old or olderNo, I am not 18 years old. I have parental and/or guardians consent with a signature below
No I am not 18 years old. I have parental and/or guardians consent with a signature. By signing below you understand the possible risks with this service.

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Print Parental/Guardians name:
first and last name
Signing below I agree I understand in full the information presented above, and freely give consent to under go the peel procedure. All questions have been answered to my complete satisfaction. The undersigned acknowledge the potential risks of a peel procedure and, except for damage resulting from the sole gross negligence of Elizaveta Neginskaya LLC. ,I agree to release Elizaveta Neginskaya LLC. & its employees and agents from any claim or liability arising out of this service.*

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REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for your self or for another individual are absolutely non-refundable. This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.*

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Date*

MonthDayYear
Date
Please fill out email to receive after care instructions. *
example@example.com
Should be Empty: