Patients Treatment Consent Form

Patients Treatment Consent Form

Skin By Jess Levin
Full Name*
Phone Number

Area CodePhone Number
Are you currently taking antibiotics/steroids and if so have you taken them in the last week?

YesNo
Do you smoke regularly?

YesNo
How often?
Do you suffer from cold sores, herpes, or hives?

YesNo
How often and where?
Do you visit tanning booths?

YesNo
Do you wear SPF daily?

YesNo
Are you epileptic?

YesNo
Are you diabetic?

YesNo
Do you have an autoimmune disease?

YesNo
Do you have heart problems or a pacemaker?

YesNo
Do you have metal plates or pins in your head or face?

YesNo
Are you pregnant or nursing?

YesNo
Do you use any prescription oral or topical medications? (Mark all that apply)

Retin-A (Tretinoin)DifferinTopical AntibioticsAccutaneMetro Gel
Do you or have you recently received any of the following? (choose all that apply)

Microdermabrasion/DermaplaneChemical PeelLaser ResurfacingInjectablesFacial SurgeryFacial Waxing
Are you allergic to any skin care ingredients?

YesNo
Which ingredients?
Describe your skin type and conditions: (choose all that apply)

ThinThickSaggySun DamagedHyperpigmentationSensitiveResilientNormalMelasmaHypopigmentationOilyDryRosaceaAcneMelasmaAcne ScarsEnlarged PoresWrinklesEczemaBroken capillaries
What improvements would you like to see in your skin?
What type of facial treatment did you last have?
What did you enjoy most and least about it?
How did you hear about us?
Consent Agreement

I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep my skin care provider updated as to changes in my medical profile and understand that there shall be no liability to Skin By Jess Levin shall I fail to do so.
Signature
Date

MonthDayYear
Date
Should be Empty: