Oxygen & Enzyme Treatment Client Intake Form

Oxygen & Enzyme Treatment Client Intake Form
Name
Date of Birth

MonthDayYear
Date
Address
City
State
Zip Code
Phone
Email
example@example.com
Occupation
Emergency Contact Name
Would you like to be added to our email list for specials and discounts?

YesNo
How did you hear about us
Medical History

Active AcneActive SunburnAutoimmune DiseaseCold Sores/ HerpesDermatitis / EczemaDiabilitiesHepatitisHIV/AIDSInfectionKeloid ScarringLactatingMelanomaNeurological DisorderOpen LesionsPregnantRadiation / ChemotherapyRashOther
Are you currently taking any medications? If yes, please list:
Have you been under the care of a dermatologist within the past year? If yes, please explain:
Do you have any known allergies? If yes, please explain.
Have you had any facial or dermatology services in the past 30 days? If yes, please explain.
Have you had aesthetic fillers, injectables or laser treatments in the last 6 months? If yes, please explain:
By Signing Below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I agree to waive all liabilty toward my technician and the salon for any injury or damages incurred dueto any misrepresentation of health.
Please Read and Agree to each of the statement below:

I have voluntarily elected to receive an Oxygen facial / Enzyme facial, and the nature and purpose of this treatment have been explained to me.I understand that this treatment can be used to diminish the appearance of fine lines and wrinkles, improve texture and tone, reduce pore size, increase hydration and moisture retention, aid in the healing of acne, and give skin a smoother appearance.I recognize there are no guaranteed results and that independent results are dependent upon age, skincondition, and lifestyle, and that there is a possibility I may require further treatments of the treated areas to obtain theexpected results at an additional cost.I understand that I may experience redness, swelling in the treatment area, but that these side effects are normal and generally subside within a few hours.I understand that although complications are very rare, sometimes they may occur and that prompt treatmentis necessary. In the event of any complication, I will immediately contact the skincare professional who performed the treatment or seek medical attention.I understand that I should not have a treatment if I intend to be in the sun or use a tanning bed.I understand that after treatment, my skin will be more susceptible to sunburn and sun damage. I understandthat it is important that I avoid excessive sun exposure and use a minimum of SPF 30 sunscreen.I have disclosed any surgical procedures, laser treatments, or facial procedures that I have had or intend on having in the future.I have not recently waxed or used a depilatory (such as Nair) on the area being treated today.I have, to the best of my knowledge, given an accurate account of my medical history, including all knownallergies or prescription drugs or products I am currently ingesting or using topically.I understand that the following conditions preclude me from having this treatment at this time and verify that none of these conditions apply to me at this time.
- History of being “highly allergic”
- Allergy to fruit
- Allergy to cocoa or chocolate
- Pregnant or lactating
- Current use of antibiotics (topical or systemic)
- Use of Accutane® within past 12-months
- Laser resurfacing surgery within past 12-weeks
- Use of glycolic acid products
- Use of Retin-A®, Renova®, or retinoids in the past 4-weeks
- Broken skin on areas to be treated
- Visible inflammation or inflammatory lesions
- Recent peels in the past four weeks
- Herpes virus (cold sores) on the mouth
- Laser hair removal within the past 6 weeks
- Currently undergoing chemotherapy or radiation treatments
I consent to the taking of photographs to monitor treatment effects and results if desired by my skincareprofessional.

YesNo
I have read and fully understand this agreement and all information detailed above. The information provided has been explained to me and all my questions have been answered to my satisfaction. I understand the procedure, accept the risks, and consent to have the treatment done. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.
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Date

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Esthetician Name
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