Returning Client - Skin Care Information and Consent

Returning Client - Skin Care Information and Consent

Date*

MonthDayYear

First Name*

Last Name*

Email for After Facial Instructions*

example@example.com

What would you like to focus on today?*

What would you like me to focus on today?

Is there a particular treatment you were interested in experiencing today (ie., micro-current, buccal, dermaplaning, oxygen dome, etc.)?

Advanced Exfoliation:

Chemical Peels: Professional chemical peels use substances such as glycolic, salicylic, pyruvic, mandelic, malic, glycolactone or lactic acid to rejuvenate skin, decrease acne, minimize the look of fine lines, wrinkles, sun damage, acne scars or hyperpigmentation, depending on which peel is used.

Spicules or Liquid Microneedles: Spicules, also known as liquid microneedles, use substances such as hydrolyzed or marine sponge, coral calcium, crystallized hyaluronic acid spears, to penetrate the skin surface to rejuvenate skin, minimize the look of fine lines, wrinkles, sun damage, acne scars or hyperpigmentation. Spicules can feel prickly upon application and for up to 72 hours after.

Dermaplaning: Dermaplaning is the use of a disposable surgical blade to exfoliate the skin and remove fine vellus hair (peach fuzz). It can minimize the appearance of surface hyperpigmentation, acne scars, fine lines and wrinkles. It may be combined with an enzyme or peel to help with penetration of nutrients. The hair that grows back after Dermaplaning will not be darker or thicker; however, any hormonal imbalance that may be present within your anatomical system can alter the normal hair growth pattern.

Hydro-dermabrasion: Exfoliates using alpha hydroxy and salicylic peels delivered through a handpiece that moves over the skin, extracts whiteheads and blackheads via adjustable suction.

Microdermabrasion: exfoliation of skin using organic flower matter or metal tip.

ReZenerate or Revitapen or Nano-Pen: exfoliation of skin using a silicone chip or metal head that infuses serums.

Possible Reactions and Complications for Advanced Exfoliation:

During Advanced Exfoliation, you may experience discomfort, warmth, redness, tingling, itchiness; spicules also feel prickly. Most of these will dissipate within a few hours. Spicules, however, can feel prickly for up to 72 hours as they keep working under the skin's surface.

After the treatment, you may experience redness, flaking, peeling, itching, dryness, tingling, stinging, irritation, heat, swelling, blistering, cold sores, allergic reactions, pimples, tenderness, scarring, discoloration. In addition, dermaplaning may result in abrasions or nicks to the skin from the sharp blade. Most side effects are temporary and will dissipate within 3-7 days.

Higher level spicule treatments, especially the Time Machine protocol, may cause significant post treatment peeling that can last beyond a week. This is why there is a required second visit scheduled within 10 days after the application of the Time Machine protocol so that a treatment to address any peeling or hydration issues can be applied. The cost of the required second visit is included in the price paid for the Time Machine protocol.

All advanced exfoliation can make discoloration or hyperpigmentation look worse temporarily, as pigmented layers under the top layer rise as the skin growth cycle progresses. This is usually a short term issue if treatment is continued. This is one of the reasons why a series and recommended home care are important.

In order to see significant results overall, these treatments need to be done in a series, and in combination with active ingredient skin care products recommended by Calm Beauty Brooklyn.

Light, Heat and Electrical Current Skin Therapies:

These skin therapies are used to tone and tighten skin and/or muscles. The possible side effects can be the same as exfoliating therapies above and dissipate in 3 - 7. days. Additonally, possible nausea, dizziness or headache can occur and usually dissipate in a few hours.

Micro-phototherapy: the application of bright light and heat for acne healing or skin rejuvenation. Also has exfoliating properties.

Light Emitting Diode (LED): A very bright, non-UV light, positioned over the treatment area for 15 minutes. Used to calm the skin, create oxygen below the surface to inhibit bacteria.

Radio Frequency: Uses mild heat and massages the skin to help with loss of elasticity (ie., mild to moderate sagging skin), tightens, firms, boosts collagen/elastin synthesis; increases skin thickness; refines pores.

Micro-current: Mild electrical current applied to skin with metal probes and gel conductor, to tone skin and muscles, stimulate nerves, and reduce some forms of pain. You may experience tingling or metallic taste during treatment.

Massage:

Used to soothe skin and nervous system, tone or relax muscles. Possible Side Effects: redness, tenderness, swelling, cold sore activation, headache, inital sagging as the tissue releases then firms later. Do not have this treatment if you have recently had facial or neck surgery, suffer from an acute face, neck or scalp injury, infectious disease, active herpes/cold sores, acute dental issues, uncontrolled thyroid disease, lymphatic system infections or blockages; take medications or herbs that thin blood/cause skin to easily bruise.

Buccal Massage with Facial Sculpting: focuses on muscles of facial expression both inside (intra-oral) and outside of the mouth. In addition to Massage side effects above, Buccal is also not suitable for those who are pregnant, have epilepsy, recent use of Botox or fillers, undergoing cancer treatment.

Gua Sha: the use of a stone to relax muscles and move lymphatic fluids.

Do you want brows or hair removal done today? If this hasn't been pre-booked, I'll do my best to accommodate.*

Have there been any changes to your health or medications since your last visit? Any new medical treatments, including any type of surgery, vaccine (tetanus, covid, flu, pneumococcal, herpes zoster), surgeries, etc? If so, please provide details. If none, write "n/a"*

What changes have you made to your skin care routine since you were last here?*

Pregnancy Status*

Have you been under the care of a dermatologist or skin care professional since your last visit with me? If so, please detail the treatments and dates. Please include injections (fillers, Botox, etc) and ANY medications.*

Have you used or had any of these in the last 30 days? Please check all that apply;*

I have completed this form truthfully and accurately.

I agree that this constitutes full disclosure and supersedes any previous verbal/written disclosures.

I understand that results are not guaranteed, and that for best results, I'll need to follow a specific home care program and/or have several treatments performed in a timeframe as recommended by my skin care therapist.

I understand that facial treatments carry risks, and that withholding information or providing misinformation may result in negative reactions, including injury. I understand that my skin care therapist will take precautions to minimize or eliminate adverse reactions as much as possible. If I experience any pain, discomfort or adverse reaction during or after the service, I will immediately inform my skin care therapist.

I understand that results are dependent on many factors, including age, lifestyle, genetic traits, cumulative sun exposure, general skin condition, health, and my willingness to follow the recommended protocols and home care outlines by my skin care therapist.

I consent to photographic and/or video documentation of my progress. All photos and videos are property of Calm Beauty Brooklyn and may be used for educational and marketing purposes, however, you will not be identifiable.

Services or information provided by Calm Beauty Brooklyn or its skin care therapists are not a substitute for medical advice or medical treatment.

I certify that I am at least 18 years old, or that I am the parent or legal guardian of the above named client.

The treatments I receive by Calm Beauty Brooklyn and its skin care therapists are voluntary, and I release Calm Beauty Brooklyn and its skin care therapists from liability and assume full responsibility thereof.

Signature*

Assessing risk and your ability to benefit from skin therapies