ZO® Skin Health Protocol: Consent Form

ZO® Skin Health Protocol: Consent Form

Client Consultation Form
Zein Obagi, MD recommends using an at-home regimen of ZO® Skin Health products to maximize the benefits.

We highly recommend screening your clients to determine who is a good candidate for the ZO® Protocol YES answers to any of the following questions may disqualify the client.

	Yes	No
Are you pregnant or lactating?
Have you used Accutane® or any prescription retinoid products (Retin-A®, Renova®) in the last 3 months?
Have you used products containing retinol in the past week?
Are you allergic or sensitive to aspirin?
Are you undergoing any type of radiation or chemotherapy?
Do you have herpes or cold sores?
Within the last week, have you had any facial waxing, electrolysis or used any depilatories?
Do you have any form of auto-immune disease (diabetes, lupus, etc.)?
Do you have a sensitivity or allergy to:
* Lactic Acid
* Citric Acid
* Salicylic Acid
* Retinol (Vitamin A)
* Latex
Have you had facial cosmetic surgery in the last month (laser resurfacing, dermabrasion, chemical peel, face lift, blepharoplasty, Botox®, injectiblefillers)?

*Note: Some redness is anticipated after the peel. It will disappear within a few minutes.

Filming may take place during any training session, for educational and marketing purposes. Models must consent to being filmed during their treatment. Our videographer can be accommodating if models prefer not to be recognisable in the final edit of the video.
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Client Signature*

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