Topical Numbing Cream Consent

Full Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthday

Date

Phone Number

Area CodePhone Number

List ANY allergies or previous adverse reactions to medications:

List ALL medications you are currently taking (including over-the-counter, Herbal Supplements or Vitamins :

Are you currently under the care of a Physician?

If yes, please explain:

Please list ALL previous surgeries:

Please list ALL current illnesses:

Please check any and all Medical Conditions that apply to you:

Do you have ALS/Lou Gehrig’s Disease?

Do you have Myasthenia Gravis?

Do you have Lamber Eaton Myasthenic Syndrome?

Do you currently smoke?

If Yes, how many packs per day?

Are you currently using any creams or lotions?

If YES, please list:

Have you ever used Accutane?

I give consent and authorization to the esthetician from Heather Brown Face and Body Studio to perform the treatment we have discussed using Topical Benzocaine/Lidocaine/Tetracaine Cream and will hold him/her and his/her staff harmless from any liability that may result from this treatment.

I understand the esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any chemical peels, skin care procedures, laser treatments or infections that I have not disclosed to my esthetician. I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my esthetician. I have informed my esthetician if I am pregnant or lactating. I am over the age of eighteen (18) or have written consent to proceed as a minor. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

I have read and understand all of the information above regarding my treatment and the information I provided is accurate and updated as of today to the best of my knowledge.

Type Name for Electronic Signature

Today's Date

Date

Topical Cream Consent - Benzocaine/Lidocaine/Tetracaine