Skin Care Waiver

Client Skin Care Consultation & Waiver
Full Name *

First Name Last Name
Client Information
Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
Occupation
How did you hear about us?
What brings you to Vivid Complexion?
Do you have any chronic medical conditions which we should know about? *

Yes No
If so, Please List:
List any known allergies:
Have you ever been treated with laser, microdermabrasion, chemical peel, or injections? *

Yes No
If so, Please List:
Are you smoker?

Yes No
Do you have a history of hypo/hyper-pigmentation? *

Yes No
Do you have a history of cold sores, fever blisters or herpes 1 or 2? *

Yes No
Are you currently taking or topically applying any medications such as Retin-A, Differing, Tazorac or Accutane? *

Yes No
If so, Please List:
Are you pregnant, trying to get pregnant or nursing? *

Yes No
Please tell us about your skin (Check all that applies):

Normal Acne Hyper-Pigmentation Hypo-Pigmentation Broken Capillaries Dry Oily Combination Melasma
Have you had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray-on tans?

Yes No
Describe your home skin care regime:
What improvements would you like to see with your skin?
Preferred massage pressure:

Light Medium Firm
By signing below, I confirm that prior to receiving my treatment, that I have been candid in revealing any condition that may have a bearing on this treatment.

I understand that there may be some degree of discomfort and there are no guarantees as to the results of this treatment, due to many variables such as condition of the skin, sun damage, smoking, climate change, age, etc.
Signature *

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Date *

- Month - Day Year
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Client Skin Care Consultation & Waiver

Client Information