Life Extender Clinic & MedSpa
Treatment Consent Form
Date
*
-
Month
-
Day
Year
Date
Legal Name:
First Name
Last Name
Sex:
*
Female
Male
Birth Date
/
Month
/
Day
Year
Date Picker Icon
Age
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Service Requested
*
List ALL ALLERGIES
*
Have you been under the care of a physician, dermatologist or other medical professional within the past year?
*
Yes
No
If Yes where?
Any recent Surgery, including plastic surgery?
*
Yes
No
If YES please explain:
Any skin cancer?
*
Yes
No
If Yes, what type?
Have you had any piercings, tattoos, or permanent cosmetics?
*
Yes
No
If Yes where?
List any over the counter medications (including any vitamins, herbal supplements, aspirin, etc.) you take regularly.
*
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/Vitamin A derivative products in the last 3 months?
*
Yes
No
If Yes please describe & explain
Have you used Acne medication prescribed by a physician in the last year?
*
Yes
No
If Yes, when? Which Drug?
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
*
Yes
No
If yes, please describe
Do you follow a restricted diet?
*
Yes
No
If yes, please explain
Are you pregnant, lactating, or trying to become pregnant?
*
Yes
No
Have you had any of these health conditions in the past or present? Select all that apply.
*
Yes
No
Cancer
Psychological Treatment
Hormone Imbalance
Systemic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Eczema
Epilepsy
Seizer Disorder
Fiver Blisters
Headache (chronic)
Hepatitis
Herpes
Immune Disorders
HIV/ AIDS
Lupus
Metal Bone Pins or Plates
Hysterectomy
Diabetes
Heart Problems
Varicose Veins
Arthritis
Asthma
Phlebitis
Blood Clots/ Poor Circulation
Insomnia
Keloid Scarring
Skin Disease/ Skin Lesions
Any Active Infection
NONE
By clicking the submit button, I agree to terms & conditions.
*
I hereby consent to and authorize Pure Skincare Solutions and its staff to perform the following procedure: Facials, Chemical Peels, Body Treatments, Microcurrent Facials, Microblading, Microneedling, Chair Massage, Microdermabrasion, Permanent Makeup, Vaginal Steaming, Laser Liposuction, Laser Hair Removal, Massage, Lymphatic Massage, and/or Sauna Capsule Treatment. I have voluntarily elected to undergo this treatment/ procedure. Although it is impossible to list every potential risk and complication, I will be informed of possible benefits, risk, and complications. I also recognize there are no guaranteed results and that independent results and dependent upon age, skin condition, and lifestyle. I am aware that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I will read the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for the post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all the information detailed above. I understand the procedure and accept the risks. I consent to the terms of this agreement. I do not hold the esthetician responsible for any of my conditions that were present, but not disclosed at the time of the skin treatment, which may be affected by the treatment performed.
Please sign that you understand the TERMS & CONDITIONS listed above.
Continue
Continue
Should be Empty: