Spa: Facial Treatment Consent/Client Profile

Personal Information

Todays Date

MonthDayYear

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone:

Area CodePhone Number

E-mail:

example@example.com

Referred by

Medical Information:

Have you seen a dermotologist in the past five years?

Reason for visit

Physicians Name

Have you had any surgery or oral surgery extractions in last 3 months?

When/ Type of surgery

Have you had a chemical peel or any type of procedure with a medical device?

Regarding having a chemical peel or previous treatment, has it been within the last 14 days?

Do you have regular collagen, Botox or other dermal filler injections?

(Peels should precede or folow injections by 7-14 days tp pevent movement of the filler or stinging at the injection site.)

Are you currently taking any medications, topical or otherwise? (Treninoin/Retin-A/Renova/Differin/Tazorac/Avage/EpiDuo/ Ziana) Which one(s)? For how long? What Strength?

Are you currently using any topical retiniod prescriptions?

If so, What kind and for how long?

( High percentaes of certian ingredients may increase sensitivty. Discontinue use at least 5 days before and after treatment. Consult your physician before discountinuing use of any prescription.)

Have you ever undergone Accutane therapy (isotretinoin)?

If so, When?

(If you are currently using Accutane therapy (isotretinion), please consult with your dispensing physician.) (If you are no longer using Accutane therpay (isotretinoin) it is OKAY to apply ONE layer of Ultra Peel 1,Sensi Peel,OXy Trio,Hydrate: Therapeutic Oat Milk Mask, or Revitalize:Therapeutic Papaya Mask.)

Are you allergic/sensitive to:

Please list any other allergies:

Please check any conditions you may have:

Please list any other medications, supplements, vitamins, diuretics, slimming tablets, ect., that you take regularly:

Please list any serious illnesses, injuries, dates of occurrance:

Are there any medical problems we should be aware of (HIV, AIDS)?

If so, please list:

Do you develop cold sores/fever blisters:

Regarding developing cold sores/fever blister: Last Breakout?

Whaty type of skin care products do you use?

What is your daily care regiment?

Do you wear SPF?

Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months

Have you recently had laser surfacing or facial surgery? If so, please describe what kind and when.

Do you have Eczema, Seborrhea, or Rosacea?

Where and what triggers your flushing?

Female Specific Information

Menopause:

Pregnant and/or Lactating

Do you currently do any type of birth control?

Endocrine Problems

Hormonal Imbalance

If you are on any birth control, hormonal or endocrine medications, please list what kind and for how long.

Last tanning or sun exposure when)?

When tanning, do you burn easily

Do you currently have a sunburned/windburned/red face?

Are you in the habit of going to the tanning booths?

Regarding tanning booth: (If within past 14 days, decline treatment. THis practice should be discountinued due to increased risk of skin cancer and signs of againg.)

Life Style/Skin Concerns:

What kind of work do you do?

Do you wear contact lenses?

How many hours a day do you spend outside?

Do you participate in vigorous aerobic activity or sports? If so, What type?

Rate your level of stress on a scale from 1-4. (1= Lowest: 4= Highest)

Do you smoke or use tobacco?

Do you have problems with healing or scarring?

Are you light sensitive?

Do you have claustrophobia

Have you ever been treated by an endocrinologist?

Please list epilation experience for the items listed below:

Laser removal date:

What is your skin complexion?

Is your skin

What concerns do you have?

Check the number that best describes your skin's response to sun exposure without SPF protection?

What do you want to improve most about your skin?

PLEASE READ: If you are receiving any of the following treatments: CHEMICAL PEEL, DERMAPLANING, MICRODERMABRASION, HIGH FREQUENCY or LED LIGHT THERAPY:
We will perform a thorough skin analysis prior to your first chemical peel, dermaplaning, microderm, high frequency or LED Light Therapy. If the treatment desired is not appropriate, you will be informed during this session and an alternative treatment may be recommended instead. If the desired treatment is not contraindicated, most services to achieve maximum results are obtained by participating in a series of treatments plus following a home care regimen. We take every precaution to ensure that your skin is well hydrated and calm following each session. However, you may experience excessive dryness or even some peeling between sessions, which may or may not be normal. Always contact us if you have any concerns. More sensitive skin may experience some redness over others. Dermaplaning and/or a Microderm may cause minor superficial abrasions which may not appear until a day or two following your treatment. If this should occur, please contact us if you have any concerns so that we can do a post-treatment follow up with you. After your treatment, SPF 30+ is a recommended MUST to be worn at all times. Tanning beds should never be used. You are making an investment in your skin: therefore, it is to your benefit to continue to protect it long after your series of treatments is completed.

CONSENT FORM:
Clients under the age of 17 must have a parent or legal guardian present to provide a signature for authorization of this facial session. Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as: tretinoin, Retin-A,® isotretinoin, Accutane,® Differin,® Tazorac,® Avage,® EpiDuo? or Ziana.® I understand there may be some degree of discomfort such as stinging, pin-prickling sensation, heat or tightness. I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc. I understand I may or may not actually peel and that each case is individual. I understand that the amount of peeling does not correlate with degree of improvement. I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximum results, I may need several treatments. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment. I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging. I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory. I have not had any other chemical peel of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location. I understand that I should follow my clinician?s recommendations for post-procedure skin care to minimize side effects and maximize results. I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-peel care instructions as I am directed.

Cancellation Policy:

We understand that unanticipated events happen occasionally in everyone's life. In our desire to be effective and fair to all clients, the following policies are honored: 24 hour advance notice is required when cancelling an appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give 24 hours advance notice, you will be asked to put a card on file before being able to rebook your appointment. If you are unable to give a SECOND 24 hour advanced notice, the canceled appointment is subjected to a cancellation fee of 40% of desired service.

Please sign here:

Skin Profile: