BODY CONTOUR CONSENT FORM

  • BODY CONTOUR CONSENT FORM

  • Date*
     / /
  • Format: (000) 000-0000.

  • CLIENT HEALTH | MEDICAL HISTORY

  • Have you used Accutane, Adapalene, Vitamin A containing topicals in the last year?*
  • Are you using any topical creams or oral antibiotics for acne, skin cancers, anti-aging or hyperpigmentation?*
  • Are you taking any oral steroids (eg. Predisone, Dexmethasone, etc.)?*
  • Do you have form of bleeding disorders or are you taking any anticoagulants (blood thinners)?*
  • Do you have any diseases of the central nervous system such as epilepsy?*
  • Do you have any autoimmune diseases such as Diabetes, Porphyria or Lupus?*
  • Do you have any chronic or acute skin diseases such as Herpes HIV, cold sores, psoriasis, eczema?*
  • Do you have skin cancer/melanoma?*
  • Have you had chemotherapy in the last 6 months?*
  • Do you have any hormonal imbalances?*
  • Do you have sun light allergies, sensitivities to the sun or histamine reactions?*
  • Have you had any laser resurfacing treatments in the last 4-6 weeks?*
  • Do you have any permanent makeup or tattooing in the last 6-8 weeks?*
  • Do you have any allergies to medications, food and/or srubstances?*
  • Have you had any injectables (Botox, Juvederm, Radiesse, Restylane, Perlane, Sillicone, Sculptra)?*

  • I understand, that I have read and completed this questionnaire truthfully. I agree this constitutes full disclosure, and that it supersedes any previous verbal and written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or adverse reactions to treatments received. I am aware that it is my responsibility to inform my Aesthetician of my current medical and health conditions and to update this history. The treatments I receive here are voluntary and I release the Aestheticians of Lux Body Lab from liability and assume full responsibility

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