Advanced Skin Treatment Forms

Please complete only the sections that apply to the treatment you are receiving today:

Including therapeutic facial massage, dermaplaning, chemical peel, hydradermabrasion, or microdermabrasion.

If you are considering other advanced skin treatments in the future, you are welcome to complete those sections as well. This helps us better understand your skin history, streamline future appointments, and ensure each treatment is performed safely, effectively, and with optimal results.
Therapeutic Facial Massage

A therapeutic facial designed to promote relaxation while improving circulation, lymphatic drainage, and muscle tension in the face, jaw, neck, and décolleté. This treatment supports skin health while providing relief from stress and tension.
Insured Member Full Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Health: Intake & Insurance Consent Form

Please send a copy/copies of your benefits card to info@rhestudio.ca; if you have more than one, send both.
Primary Provider
Member ID
Policy Number
8. Botox/Fillers (List areas & date:
9. Pregnancy? (If yes, how many weeks):
10. Other relevant health conditions:

Rows	Yes	No
1. TMJ Disfuction
2. Jaw Clenching/Grinding
3. Headaches/Migraines
4. Sinus Issues
5. Facial Surgeries (Past/Upcoming)
6. Recent Dental Work (within last 4 weeks)
7. Skin Sensitivities or Allergies
8. Botox/Fillers (List areas & date:
9. Pregnancy? (If yes, how many weeks):
10. Other relevant health conditions:

I understand the nature of this treatment and have disclosed all relevant medical and skin history.I give permission to receive facial massage and/or buccal massage, understanding the therapeutic intent.I understand that this treatment is covered under massage therapy scope of practice and may be eligible for health benefits.I acknowledge that skincare products will be used based on my skin type and that any sensitivities should be disclosed prior to the session.
I agree to the terms of service
Yes (Social Media)Yes (Social Media - No fac)Yes (Personal documentation only)No
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear

Dermaplaning Consent

Dermaplaning will exfoliate the superficial dead skin and remove the vellus hair (peach fuzz), leaving my skin smoother, brighter, and the ingredients will penetrate deeper immediately after, and makeup application will appear flawless.
Name
Phone
Format: (000) 000-0000.
Email
example@example.com
I, voluntarily consent to RHE Studio's certified technicians to perform a dermaplaning treatment on my face; I understand the procedure as explained, the risks although rare, and the usual results.
Full Name
List current medications and supplements:
Initial below if you acknowledge the following:
I have disclosed all medications to the service provider.
Initial
I have been made aware that Full Block Protection, summer and winter, will ensure a better result with treatment and my future skin health.
Initial
Photos are taken for accurate record keeping purposes and showing progress to client and technician.
Initial
Pre, post treatment, and ongoing maintenance has been thoroughly explained to me.
Initial
Following instructions will minimize complications although rare.
Initial
Slight redness, stinging, slight skin nicking, or darkening may occur and will subside in 2-7 days.
Initial
I waive all claims, for injury, pain, and suffering, or other personal loss or damages that I have or may have in the future against, and release, and forever discharge RHE Studio, from all liability and all actions, causes of action suits, contracts, claims, and demands whatsoever which I may have against RHE Studio.
Initial
I am over 18 years and understand my consent is required before treatment.
Initial
Yes (Social Media)Yes (Social Media - No fac)Yes (Personal documentation only)No
Date:

MonthDayYear
Date
Client Signature:

Powered by Jotform SignClear

Hydro/Micro Dermabrasion Consultation & Consent Form

A non-invasive exfoliation treatment that removes dead skin cells while improving skin texture and tone. Hydradermabrasion uses water-based technology to cleanse, exfoliate, and hydrate the skin, while microdermabrasion uses a mechanical method for deeper resurfacing.
Name

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Initial the following:
Your skin may experience temporary irritation, tightness, or minor bruising & redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.
Initial
You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.
Initial
Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
Initial
You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain results.
Initial
The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.
Initial
Do you have any of the following:

Rows	Yes	No
1. Any open cold sore or lesion?
2. An active infection in the treatment area
3. Active sunburn
4. An autoimmune disease such as lupus
5. A viral concern such as HIV or hepatitis
6. Metal or Active implants/pace maker etc (RF, BIO)
7. Skin conditions such as eczema, dermatitis, or rashes
8. Melanoma or lesions suspected of malignancy (RF, BIO)
9. Pregnancy or Lactation (RF, BIO)
10. Neurological disorders such as Epilepsy (LED Light)
11. Infection in the urinary system i.e. kidneys, bladder, urethra (Lymphatic Drainage)
12. Crohn’s Disease (Lymphatic Drainage)
13. Hyperthyroidism (Lymphatic Drainage, RF, BIO)
14. Deep Vein Thrombosis (Lymphatic Drainage)
15. Lymphedema (Lymphatic Drainage)

Have you recently:

(Yes or No)
1. Used Accutane, topical medications or antibiotics?
2. Had aesthetic fillers, injectibles or laser treatments (past 2 weeks)
I consent to the following:
1. I will avoid the use of tanning beds, aggressive exfoliation, waxing, and products containing glycolic acids or retinols, hydroxy's that are not part of the recommended take-home regimen in the treated areas for a minimum of 1 week post- treatment. (Avoidance of ordinary make-up for 24hrs post treatment)

2. I Hereby Authorize the performance of the treatment as outlined above, and I acknowledge that I have been informed of

3. the procedure, its benefits, and any potential risks/side effects involved.
Yes (Social Media)Yes (Social Media - No fac)Yes (Personal documentation only)No
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Therapeutic Facial Massage

General Health: Intake & Insurance Consent Form

Dermaplaning Consent

Initial below if you acknowledge the following:

Chemical Peel Consent

Hydro/Micro Dermabrasion Consultation & Consent Form

Initial the following:

Do you have any of the following:

Have you recently:

I consent to the following: