MEDIK8 CLIENT CONSENT FORM PROFESSIONAL TREATMENT

MEDIK8 CLIENT CONSENT FORM PROFESSIONAL TREATMENT
Name *

First Name Last Name
Date *

Day Month Year
Current Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Telephone No *
Email *
example@example.com
Date of Birth *

Day Month Year
Date of birth

Health History
Please tick where applicable if you have any of the following conditions:

Kidney / liver disease Significant immunosuppression Use of antibiotics for last 6 months Ehlers-Danlos Syndrome Prescription Strength Vitamin A for last 6 months Scleroderma / vascular disease Pregnant or nursing mums Heart disease / blood pressure Allergy to aspirin Metal plates or pins Diabetes Active bacterial, viral or fungal infections Epilepsy Asthma Cancer
Health History
Please tick where applicable if you have any of the following conditions:

Psoriasis Eczema Rosacea Thread Veins Pigmentation Dry Skin Dermatitis Acne Moles Sensitive Skin History of cold sores Sun Damage
Precautions
Are you allergic or ever had any adverse reactions to:

Medications Cosmetics Alcohol Clothing Shampoo Hair dye Foods Jewellry Soap Skincare Perfumes
Have you taken any medication for a skin condition in the past? *

Yes No
If yes, please provide details:
Details of skin condition
Are you currently taking any medications? *

Yes No
If yes, please provide medication details:
Medication details
Have you had any medical / health problems in the last 12 months?

Yes No
If yes, please provide problem details:
Medical/health problem details
Are you pregnant or planning a pregnancy? *

Yes No
Have you received any injectable treatments (ie. Botox) in the last 24 hours? *

Yes No
Lifestyle
Have you recently had any change in your diet, lifestyle or beauty regime? *

Yes No
Pre Chemical Peel Contra-indications that indicate the peel should NOT be performed;(Please tick where appropriate)

Inflamed acne cyst Recent Retin-A use Active herpes Recent depilation (48 hours) Roacutane use Irritated or damaged skin Open cuts in the area Sunburned skin Severe physical or mental stress Allergy to Medik8 homecare products
Please note facial masks, manual +AHA / BHA exfoliators and enzymatic peels should not be used 48 hours prior to receiving a Medik8 Superficial Level 1 or Jessner Peel. Microdermabrasion, laser resurfacing and other facial treatments such as chemical peels, botox, skin fillers, IPL and plastic surgery should be completely healed.
Skin indications for the treatment:(Please tick where appropriate)

Acne and / or acne scarring Blocked pores / follicles Facial erythema Photo damage Dry, dehydrated skin Dull skin Fine lines & Wrinkles Improve skin texture
Medik8 Pre Treatment Homecare Regime:
Please confirm that you have been using Medik8 skincare for two weeks prior to this treatment and list which products you have been using regularly.
Pre Treatment Homecare Regime
I have re-read the Consent Form and no skin indications, contra-indications have changed since my last visit. There has been no change to my health.

The skin care specialist has explained to me the above indications and contraindications of the Medik8 treatment to be performed on my skin, which I fully understand. I agree that a skincare specialist can perform this series of treatments. I understand that a mild redness and / or irritation may occur. This is a temporary reaction that will subside. I understand that I must wait 24 hours after each treatment (or longer until redness and/or irritation has completely subsided) before resuming the use of Medik8 home care products that contact AHAs, BHAs or Vitamin A. I understand that to obtain maximum results from the peels, I must have a series of treatments and use in conjunction with a Medik8 home care program. I understand that due to the variable nature of the
human skin, no guarantee can be made to me regarding the results of this treatment.
Client's Signature *

Clear
Print Name
Date of Signature *

Day Month Year
Date of signature
Should be Empty:

MEDIK8 CLIENT CONSENT FORM PROFESSIONAL TREATMENT

Health History

Health History

Precautions

Lifestyle

Medik8 Pre Treatment Homecare Regime: