PURE SKINCARE
Treatment Consent form
Today's Date:
*
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Month
-
Day
Year
Date
Legal Name:
First Name
Last Name
Sex:
*
Please Select
Male
Female
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2024
2023
2022
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2020
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2012
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1924
1923
1922
1921
1920
Year
Age
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name
*
First Name
Last 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?
*
Yes
No
If Yes where on your person?
Any recent surgery, including plastic surgery?
*
Yes
No
If YES please explain:
Any skin cancer?
*
Yes
No
If Yes, what type?
Have you had any piercings, tattoos, or permanent cosmetics?
*
Yes
No
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?
*
Yes
No
If Yes please describe & explain
Have you used Acne medication prescribed by a physician in the last year?
*
Yes
No
If Yes, when? Which Drug?
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
*
Yes
No
If yes, please describe
Do you follow a restricted diet?
*
Yes
No
If yes, please explain
Are you pregnant, lactating, or trying to become pregnant?
*
Yes
No
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:
Submit
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