Facial Consent and Release Form

CLIENT CONSULTATION AND RELEASE FORM

Please read carefully, complete, sign and date this form prior to your treatment.
Name *

First Name Last Name
Phone *
Address *
City *
State *
Zip *
Email *
Birthday Date *

Month Day Year
Date
Section 1: MEDICAL INFORMATION
Do you have any of the following allergies? *

Shellfish Asprin Sulfur Preservatives None Other
Please check all that apply: *

Accutane or other similar medication Autoimmune disease, HIV, lupus, hepatitis Blood thinners - Heparin, Coumadin, Warfarin, etc.Cancer or post-cancer treatments Breastfeeding/pregnancy Cancer or post-cancer treatments Cardiovascular problems Cold sores or fever blisters without pre-medication Cortisone or steroid injections Cosmetic injections, fillers or implants, (i.e. Botox® collagen) Eczema, psoriasis within the last 14 days Eczema, psoriasis Epilepsy Facial waxing services w/in 7-14 days Hypertension/high blood pressure Inflammatory conditions Irregular, pigmented moles, warts or growths, unidentified facial growth or mark Keloids, pigmented scars, icepick scars, new scar tissue Laser procedures, chemical peels, dermabrasion, microdermabrasion Lymphatic disorder, inflammation of lymph vessels, lymphedema Loose, thin, aged skin Recent accident or serious injury Recent surgical or dental procedure Rosacea, telangiectasia/couperose Retin-A, Retinol Skin-lightening or bleaching agent Thyroid disorder Type 1 diabetic Under medical care for an existing or suspected condition or disease Viral infection, influenza, COVID-19 Other contraindication at discretion of skincare technician or medical practitioner: None
If you answered YES to any of the above questions please explain
My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyperpigmentation, scarring, etc.)
Specify your areas of concern (i.e. eyes, forehead, etc.)
SECTION 2: CLIENT CONSENT FORM Please check box to acknowledge *

1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months. 2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment. 3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen. 4. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. 5. I have disclosed my history of allergies above. 6. I acknowledge that if I am allergic to one or more of the ingredients in the products used, I may experience allergic reactions. 7. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure, especially between 10am - 2pm. 8.I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. 9. I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following the treatment. 10. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my skincare practitioner during and following the treatment. 11. I acknowledge that I am not pregnant/lactating. 12. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. 13. I acknowledge that I have answered all questions truthfully and completely. 14. I release Edge Systems, Serenity Studio Skin & Body from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. 15. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. My name will not be used to identify these photographs without my written approval. 16. I acknowledge promptness is greatly appreciated; arriving late will limit my treatment time, as my treatment will end on time so the next guest is not delayed. Late clients are responsible for full service fees. 17. I acknowledge we request a 24-hour notice of cancellation. If appointments are not cancelled within 24 hours, you may be charged 100% of the treatment fee
By signing below, I certify that I have read and fully understand the contents of this consent form and that the information I provided above are complete, accurate and up-to-date to my knowledge.
Client Signature *

Clear
Date *

Month Day Year
Date
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