Please fill in the requested information to assist your skin care professional in analyzing 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. 

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 or so. consult with your physician prior to treatment and avoid the HydroPeptide Pumpkin Peel Recent facial surgery. allergies, tendency to cold sores/fever bisters. use of topical and/or oral prescription medications such as: Tretinoin, Retin- A tsotretinoin, Accutane Dirferin, Tazorac, Avage, EpiDuo or Ziana.

I UNDERSTAND THAT THERE MAY BE SOME SLIGHT TINGLING OR PIN-PRICKING SENSATION

I UNDERSTAND THERE ARE NO GUADANTEES AS TO THE RESULTS OF THIS TREATMENT DUE TO MANY VARIABLES SUCH AS: AGE. CONDITION OF SKN, SUN DAMAGE, SMCIONG 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 MOROVEMENT

I UNDERSTAND THIS IS A COSMETIC TREATMENT AND THAT NO MEDICAL CLAIMS ARE EXPRESSID OR IMPLIED

I UNDERSTAND TO ACHIEVE MAXMUM 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 WILL IMMEDIATELY CONTACT THE CLINCIAN WHO PERFORMID THE TREATMENT

I UNDERSTAND THAT EXTENDED DIRECT SUN EXPOSURE IS PROHIBITED WHLE AM UNDERGOING TREATMENTS, AND THE DAILY USE OF SUNSCREEN PROTECTION WITH A MINMUM OF SPF 30 IS MANDATORY

I UNDERSTAND THAT I SHOULD FOLLOW MY CLINICIAN'S RECOMMENDATIONS FOR POST- PROCEDURE SKIN CARE TO MINIMIZE SDE EFFICTS AND TO MAXIMIZE RESULTS

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

I am a small business & I rely on your appointment for the support of my business & scheduling for other clients. If you are unable to make your scheduled appointment time please allow as much time as possible so I can offer your spot to other clients.

At least 72 hours prior to your appointment is preferred. A 50% cancellation fee will be charged for cancellations within 24 hours prior to the scheduled appointment.

If you’re 15 minutes or later for your scheduled appointment time, rescheduling will be required.

A 100% no-show fee will be charged for all no-show/no-call appointments.

Thank you for your understanding, respect and support. Please never hesitate to reach out!

xx