Jet Peel Intake and Consent Form

Today's Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Phone Number

Email*

example@example.com

How did you hear about us?*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

Any recent surgery, including plastic surgery?*

YesNo

If yes, please explain:

Do you have or have ever had any of the following?*

If other, please explain:

Any known allergies (check all that apply)?*

Please list any other allergies or sensitivities:

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*

Do you (check all that apply)?*

Are you pregnant or breastfeeding?

YesNo

Are you taking birth control or hormone replacement?

YesNo

Have you had a facial treatment before?*

YesNo

If yes, when was your last facial or skin treatment?

Date

Are you currently using any products that contain or are you taking any of the following?*

Have you received any of these skin care treatments?*

If you checked any of the above, please select one:

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 months

Have you ever had an adverse reaction after using any skin care product?*

YesNo

If yes, please check all that apply:

Have you had Botox or other injectables?*

YesNo

If yes, date of last treatment?

Date

What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*

YesNo

Do you have frequent breakouts?*

YesNo

What skin care products do you currently use?*

Do you use sunscreen?*

AlwaysOftenSometimesNever

What are your specific concerns at this time regarding your skin?*

What is your skin care goal?*

Indicate The Jet Peel facial you are interested in:

Anti-agingAcneATX-NAT (natural botox)Lymphatic Drainage

Signature*

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following:

JetPeel is a safe and highly effective, clinically proven procedure to deeply exfoliate and infuse neutrcuetical solutions into the skin. JetPeel is indicated and is customized to treat various dermatological conditions including but not limited to acne, photodamage, hair loss, excessive sweating, rosacea, fine wrinkles.

I give the staff at Qskins Laser & Aesthetics consent to preform JetPeel Dermal Infusion as an elective cosmetic procedure. I acknowledge that this is a safe and effective procedure however I understand that in the rare case there may be risk of the following:

I acknowledge that after the procedure that my skin may experience temporary erythema, irritation, tightness and slight swelling, these reactions will usually resolve within 72 hours post procedure, depending on the sensitivity of the skin.

I understand that I may experience itching, tingling and possible increased skin sensitive post procedure, these sensations will dissipate post procedure.

I acknowledge that if I suffer from active acne this condition may worsen before showing improvements. Additional treatment may be required to achieve resolution of the acne condition.

I understand that if I have a history of cold sore (Herpes Simplex) in the facial area I need to make my treatment provider aware, as I may need a prescription to prophylactically treat this condition to avoid an outbreak post procedure. I will avoid this treatment if I have an active outbreak.

I acknowledge that I will disclose to my treatment provider if I am pregnant or nursing prior to the commencement of this treatment.

I acknowledge that there are no guarantees the accompany this treatment, as result may vary based on individual skin type and condition. I understand that I may need multiple treatments to achieve my desired results.

I understand that JetPeel will make my skin more UV sensitive for 72 hours post procedure, I must ensure during this time it is my responsibility to apply a physical sunblock as my skin during is more prone to burning during this time.

I consent to having my photo taken for clinic use to evaluate the efficacy of the treatment. I understand that these photo will in no way be used for publication purposes.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.

I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.

I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so they can adjust
accordingly.

I have been given a chance to ask questions about the session
and my questions have been answered.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

I, therefore, release Qskins Laser & Aesthetics from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Jet Peel Facial Intake and Consent Form

Medical History