Client Facial treatment authorization form

This is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.

name*

birthday*

Email address *

Phone number *

address*

aptunit

city

state*

zip*

1. What treatment are you receiving today!*

2.I give consent for pictures and videos for content and upkeep purposes *

3 Within the last year, have you had any health problems that have affected or could affect your skin?*

4 Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 2 weeks? *

5 Have you been waxed within the last 1-2 week?

6 Are you prone to keloid scarring, blisters, or cold sores?

7 Have you used retinol, tretinoin or any other prescription skin products within the last three months such as Glycolic Acid , Other Hydroxy Acids or any exfoliating scrubs Vitamin A derivatives (i.e., Retinol)*

8 List any medications supplements vitamins diuretics oral contraceptives Isotretinoin etc that you take regularly*

9. Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments?*

10. Are you pregnant/trying to become pregnant ,pre-menstrual menstruating?*

11. Do you have metal implants, a pacemaker or body piercings?*

12. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?

13. Do you have active cold sores?*

14. Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks?*

15. Do you sunbathe or use tanning beds?

16. Have you ever experienced claustrophobia?

17. Do you experience redness, itching, or stinging on your skin?

18 What are your specific concerns challenges with your skin?*

19.how did you hear about Natural Beau . First Name Last Name

Would you like to start your home care regimen with us today?*

What skin care products are you currently using ?*

	Brand name	Would you like to hear options ?
Cleanser
Toner
Exfoliation
Masque
Moisture/ spf

pro power peel: Precautions & Warnings
1. Skin may appear flushed following the treatment.
2. Peeling may begin within 2-3 days. DO NOT pick at loose skin, as this may cause discoloration.
3. Avoid direct sun exposure for 2-3 weeks to prevent hyperpigmentation.
4. Avoid sweaty exercise on the day of treatment, along with or steam rooms.
5. Avoid any type of exfoliating product until directed otherwise by Professional Skin Therapist.
Contraindications for power peel: prone to post-inflammatory hyperpigmentation or keloid scars open skin lesions recent sun exposure use of isotretinoin currently or in the past six months history of diabetes severe rosacea or acne
Microneedling precautions & warnings
1. Discontinue use of retinoid (Retin-A) and/or any form of skin treatment 3 days prior to procedure, under care and direction of a physician.
2. Not for active acne, rosacea, or other inflammatory skin conditions. Not for skin with piercings in treatment area or open wounds.
3. Not to be administered for 6 months to 1 year after isotretinoin (Accutane) regimen.
4. Not for clients with facial outbreaks such as herpes simplex virus. Medication must be taken per doctor's instructions.
5. Not for clients with metal allergies or skin allergies.
6. Any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment, under the care and direction of a physician.
7. For any recent face lift or eyelid surgery, seek advice from your surgeon regarding how soon you can receive treatment.
8. Not for clients who have had dermabrasion, remodeling, deep chemical peels, or any surgical procedure on the treatment area within the previous 3 months.
9. Not for clients who have had neurotoxin injectable (Botox), or other injectables such as collagen, fat, or other methods of augmentation in the targeted area within 14 days.
10. Not for clients who have excessively tanned or sunburned skin from the sun, tanning beds, or tanning creams within previous 14 days.
11. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-treatment.
12. Fitzpatrick skin types 4-6: pigment may darken prior to lightening.
13. You may experience redness for up to 3 days.
14. You may experience inflammation, itching, and burning.
15. Consult a physician if any irritation persists.
Contraindications for Microneedling : history of hemophilia, irregular blood pressure,history of eczema, psoriasis and other tuberculosis, liver function issueschronic conditions susceptibility to capillary ectasia due to steroid usehistory of actinic (solar) keratosis, diabetes, for extended periods*raised moles or warts on targeted area cardiac abnormalities, pacemaker, blood clotting problems*collagen vascular disease active bacterial or fungal infection; (i.e., cold sore) blood thinning medication* immunosuppression*history of any type of cancer facial melanosis* pregnant or nursing keloid scars Nanoinfusion:Microneedling
Dermaplaning precautions and warnings
skin may be a little tender and flushed for 3 days
red, discolored or itchy feeling 2-3 days
can be dry afterwards apply moisture
avoid direct sun exposure and extreme heat
do not scrub or exfoliate for a week
use sunscreen
gentle cleansers
do not wear makeup 24 hours
avoid tanning beds, saunas, swimming pools for 3 days
Contraindications for dermaplaning: current, inflamed acne lesions open skin lesions skin canceruse of Accutane currently or active cold sores in the past six months uncontrolled diabetes, radiation or chemotherapy , dermatitis , blood thinners, rosacea, keloid prone skin, Lupus, Moles

I understand that results will vary between individuals. I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The procedure contraindications, precautions and warnings have been explained to me including alternative methods, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be fully anticipated. Therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. am aware that the results of this treatment with Dermalogica are not permanent as natural degradation will occur over time.

| have read this consent form and I understand the information contained in it.

I have had the opportunity to ask any questions about the treatment, including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. I confirm that the information I have provided on this form is accurate, to the best of my knowledge, and that have not withheld any information that will be relevant to my consultation.

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