Oxygen Rx and Enzymes Consent & Health Questionnaire

Oxygen Rx and Enzymes treatment Consent & Skin Questionnaire

Please fill out completely
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Emergency Contact *

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
How did you hear about us?*

InstagramGoogleFacebookFamily/FriendWalk InOther
It is very important that you read ALL of the information in this document, sign it, and submit. This confirms that you understand precautions for the treatment.

- I agree to complete this form in it's entirety, and to be truthful about my physical conditions, pregnancy, medications that I may be taking, and my current skin care regimen. I am also aware that my lifestyle, which if it includes smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or recreational use of controlle substanceds, will affect and diminish the effectiveness and result of the treatment.

- I have disclosed to my skin care professional any surgical procedures, laser treatments, or facial procedures that I have had or intend on having in the future.

- I am not presently pregnant or lactating.

- I have not had any recent chemotherapy or radiation treatments.

- I have not recently waxed or used a depilatory (such as Nair/Magic Shave) on the area being treated the day of treatment. I do not have a history of keloid scarring, diabetes, any autoimmune disease, active herpes blisters, or cold sores.

- I understand that I should not have a treatment if I intend to be in the sun or use a tanning bed, and will refrain from excessive sun exposure and the use of a tanning bed while I am undergoing treatment.

- I have disclosed to my skin care professional any treatments of any kind that I have received within 14 days of this treatment whether the treatment was performed at this location or any other location.

- I understand that my practitioner may recommend home care products to work in tandem with the treatment. I am wiling to follow recommendations by my skincare professional for home care, including sunscreen.

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:

-- Allergy to citric fruits (oranges, limes, grapefruit, lemons)

-- Allergy to cocoa, chocolate and/or raspberry

-- Allergy to pineapple and/or papaya

-- History of being "highly allergic" to anything

-- Pregnant or lactating

-- Current use of antibiotics (topical or systemic)

-- Use of Accutane within the last 12-months

-- Laser resurfacing surgery within the last 12-weeks

-- Currently use of glycolic acid products

-- Use of Retin-A, Renova, retinoids (Vitamin A) in the last 4-weeks

-- Broken Skin on areas to be treated

-- Visible inflammation or inflammatory lesions

-- Recent peels within four weeks

-- Herpes virus (cold sores) on mouth

-- Laser Hair Removal within 6 weeks

-- Currently undergoing chemotherapy or radiation treatments
I understand, and agree to, and will adhere to, the above conditions.*

Yes
I give my permission to my skin care professional to perform the following treatment:*

Oxygen Rx TreatmentCocoa EnzymeZymase Enzyme
My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be necessary. The rate of improvement depends on my skin type, condition, age, degree of sun damage, or pigmentation levels.*

Yes
Have you had an Enzyme treatment and/or Oxygen Rx treatment before?*

YESNO
Have you ever had any issues with your previous treatments?*

YESNO
What were the issues?*

Break outsReactionOther
How would you describe your skin?*

NormalCombination (ex. Oily Tzone but dryness on chin)DrySensitiveOilySun Damaged
What are your specific skincare concerns or like to improve?*

Dryness/ flaky skinFine Lines and wrinklesBlackheadsAcneLoss of FirmnessAcne ScarsClogged PoresSkin TextureEnlarged PoresHyperpigmentation/Uneven toneRednessSkin SensitivityRosaceaOily SkinSkin dullness/brighteningOther
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
What is the skincare brand you use?*

I don't use skincareOther
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsTopical AntibioticsAccutaneDifferinRetin-ATazaracRenovaHydroquinoneNo/NoneOther
When, and how long have you been taking these products?
Have you ever received chemical peels, laser services, facial waxing, or microdermabrasion treatments?*

YES, within the last monthYES, within the last 2-3 monthsNO
Have you received botox or fillers?*

YesNo
You selected "Yes" to Botox or fillers, please list what location on your face and when?
Medical History Questionnaire
Any known allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential oilsTree NutsDairySunscreenPollenGlutenEggSoybeanNoneOther
Please list medications and/or supplements you are currently taking:
Medications / Supplements
Have you ever experienced claustrophobia?*

YESNO
Have you ever experiences vertigo or issues laying flat?*

YESNO
Have you experienced any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart disease/ ConditionsArthritis/BursitisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold sores/blistersHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesBruise easilyMetal ImplantsPacemakerSmoker/Former SmokerHepatitisNoneEczemaPhlebitisVaricose VeinsThrombosisHyperthyroidismHypothyroidismCataractsContact LensesHay FeverMenopausalNoneDental metal fillings/bridgeworkOther
You selected "YES" to Varicose veins. If Varicose veins are present on the face specifically, and tends to be severe, please indicate it here for the treatment plan to be adjusted:

YesNo
You selected "YES" for Phlebitis, please be advised due to pain, swelling and risk for blood clots any massage will be omitted to reduce risk. Please confirm that you are cleared by a physician to have this treatment:

Yes
You checked "YES" to Cataracts, please be advised due to pressure applied from massage or exfoliation during a facial, this treatment shouldn't be performed with any recent Cataract surgery. Please confirm that you are post surgery and/or cleared by a physician to have this treatment:

Yes
For WOMEN: Please select All that apply:

Taking birth controlPregnant or breast feedingTaking hormone replacementExperience hormone imbalancesNone of the aboveOther
For MEN: Please select All that apply:

Shave with an Electric ShaverShave with RazorExperience skin breakouts after shavingExperience Ingrown hairNone of the aboveOther
Informed Consent / Waiver Release Policies
Informed Consent / Waiver Release

I hereby agree to this treatment. I am aware that products used in facials, skincare treatments, and homecare may contain tree nuts, sulfur, dairy, fruit, and gluten. I acknowledge that the skin care professional with Array Esthetics & PMU may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of adverse reaction to a product used in facials. I will inform my skin care professional before treatment of severe allergies, as this may make me unable to receive the service.

I am aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed all my known medical conditions, skin conditions, allergies, medications, and answered all questions honestly on the above form, and agree to update Array Esthetics & PMU as to any changes. I understand it is my responsibility to disclose all medical, medicinal, and skin history, as Array Esthetics & PMU will not be responsible for reactions caused by undisclosed medical history.

I understand that the services offered are not a substitute for medical care. I understand that my skin care professional with Array Esthetics & PMU will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and post care procedures to the best of my ability, so that I may obtain maximum effectiveness. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. Should any complications occur, I will immediately contact the skin care professional who performed the treatment. In the event that I may have additional questions or concerns regarding my treatment or suggested home care routine, I will inform my skin care professional immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and understand the potential risks and complications and I have chosen to proceed with the treatment after careful consideration of both known and unknown risks, complications, and limitations. I release and hold harmless the skin care professional and Array Esthetics & PMU from any liability for adverse reactions that may result from this treatment.

Policies

1. If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is the policy of Array Esthetics & PMU to provide you with the best professional service and products customized for your skin goals.

2. 24- hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. By clicking the box, I’m acknowledging I have read, understand, and agree with the terms of these policies.

This agreement will remain in effect for the procedure and all future procedures conducted by my technician for one year from the date of this signed form. I understand that this agreement is binding and that I have read and fully understand all information listed above.
I consent to any relevant photographs/videos being taken before and after the procedure to document the results of the procedure to be used for internal purposes.*

Yes
[Optional/Requested] I consent to Array Esthetics & PMU to use "before & after" photos/ videos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at anytime withdraw such consent for specific photograph/videos by contacting the company, which will then discontinue use of said photo/video(s).*

YesNo
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Oxygen Rx and Enzymes treatment Consent & Skin Questionnaire

Medical History Questionnaire

Informed Consent / Waiver Release Policies