Client Consent for Facial treatments

  • Facial Treatments

  • What is your hereditary background? *

  • Describe your skin*

  • Are you pregnant or lactating?*
  • Do you wear contact lenses?*
  • Are you exposed to the sun regularly or are you considering spending time in the sun soon? *
  • Do you use a tanning bed? *
  • Do you smoke or use tobacco? *
  • Do you currently use depilatories or wax on your face?*
  • Have you used any facial rollers in the past 2 - 4 weeks*
  • Have you had any chemical peel or any type of procedure with a medical device in the past?*
  • Do you have regular collagen, Botox or other dermal filler? *
  • Have you recently had laser resurfacing or facial surgery?*
  • Are you currently taking any medications, topical or otherwise?(Tretinoin/Retin-A®/Renova®/Differin®/Tazorac®/Avage®/ EpiDuo®/Ziana®) *
  • Have you ever undergone Accutane® therapy (isotretinoin)?*
  • Are you using any other skin thinning products and/or drugs? *
  • Do you develop cold sores/fever blisters? *
  • Are you currently taking medications?*
  • Do you have any allergies? *
  • Have you ever used any other products that caused a bad reaction?*
  • Have you ever been treated for skin cancer?*

  •  I understand there may be some degree of discomforts such as stinging, pin-prickling sensation, heat, or tightness.

    I understand there are no guarantees as to the results of this treatment, due to many variables, such as age, condition of the skin, sun damage, smoking, climate, etc.

    I understand that results will vary among individuals.                                     

    I understand that although I may see a change after my first treatment, I may require a series of sessions to obtain my desired outcome.                                         

    I am aware that although good results are expected, the possibility and nature of complications cannot be accurately advised; therefore, there can be no guarantee, expressed or implied, either the success or other results of the treatment.                                       

    I am aware that treatment is not permanent and natural degradation will occur over time.                          

    I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.

    I understand that to achieve maximum results, I may need several treatments.

    I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the clinician who performed the treatment.

    I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment, and during the 14 days prior to and following the end of treatment. This practice should be discontinued due to the increased risk of skin cancer and signs of aging.

    - If you receiving a peel
    I understand I may or may not actually peel and that each case is individual.

    I understand that the amount of peeling does not correlate with the degree of improvement.

    I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum SPF of 30 is mandatory.

    I have not had any other chemical peel of any kind within 14 days of this treatment.

    I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.

    I understand that I should follow my clinician’s recommendations for post-procedure skincare to minimize side effects and maximize results.                 

    If applicable I further agree to follow all post-peel care instructions as I am directed.

    I hereby agree to all of the above and agree to have this treatment performed on me.

  • By signing below you agree to terms and conditions.

    THIS CONSENT FORM IS VALID UNTIL ALL OR PART IS REVOKED BY ME, THE BELOW SIGNED PATIENT, IN WRITING:

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