Treatment Consent form

Today's Date:*

Date

Legal Name:

First NameLast Name

Sex:*

Birth Date

MonthDayYear

Age

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email Address

example@example.com

Emergency Contact Name *

First NameLast Name

Emergency Contact Number

Please enter a valid phone number.

Service Requested*

Facial, Sauna Capsule, Massage, Body Treatment, Permanent Make-Up

List ALL ALLERGIES*

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*

YesNo

If Yes where on your person?

Any recent surgery, including plastic surgery?*

YesNo

If YES please explain:

Any skin cancer?*

YesNo

If Yes, what type?

Have you had any piercings, tattoos, or permanent cosmetics?*

YesNo

If Yes where?

List any over the counter medications (including any vitamins, herbal supplements, aspirin, etc.) you take regularly.*

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/Vitamin A derivative products in the last 3 months?*

YesNo

If Yes please describe & explain

Have you used Acne medication prescribed by a physician in the last year?*

YesNo

If Yes, when? Which Drug?

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?*

YesNo

If yes, please describe

Do you follow a restricted diet?*

YesNo

If yes, please explain

Are you pregnant, lactating, or trying to become pregnant?*

YesNo

Have you had any of these health conditions in the past or present? Select all that apply.*

	Yes	No
Cancer
Psychological Treatment
Hormone Imbalance
Systemic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Eczema
Epilepsy
Seizer Disorder
Fiver Blisters
Headache (chronic)
Hepatitis
Herpes
Immune Disorders
HIV/ AIDS
Lupus
Metal Bone Pins or Plates
Hysterectomy
Diabetes
Heart Problems
Varicose Veins
Arthritis
Asthma
Phlebitis
Blood Clots/ Poor Circulation
Insomnia
Keloid Scarring
Skin Disease/ Skin Lesions
Any Active Infection
NONE

If you answered 'yes' to any of the above questions, please give details:

PURE SKINCARE