Obey the rules of this electronic skincare consent waiver. Avoid the sun for 7 days after the skin care treatment.

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Skincare Treatments – Client Questionnaire

First and Last Name: *Please enter your name.

Date of birth:

Please enter valid date.

Email: *Please enter your email.

Phone number: *Please enter your phone number.

How did you hear about us? Please enter your answer here.

The name of person who referred you to us? Please enter your answer here.

Do you have any current medical conditions? YES / NO If yes, please list: *Please enter your answer here.

Are you taking any medications? YES / NO If yes, please list: *Please enter your answer here.

Do you have any allergies? YES / NO If yes, please list: *Please enter your answer here.

Have you had facial waxing, laser treatment, Botox and/or other injections within 2 weeks? *

YES

NO

Please select at least one choice above.

Are you exposed to the sun on a daily basis or do you use a tanning bed? *

YES

NO

Please select at least one choice above.

Are you pregnant or trying to become pregnant? *

YES

NO

Please select at least one choice above.

Do you use SPF on daily basis? *

YES

NO

Please select at least one choice above.

Do you reapply SPF every 2 hours if you are outside? *

YES

NO

Please select at least one choice above.

What are your goals for your skin? Please enter your answer here.

Please read and initial:

Initial Here

Initial

I understand a facial treatment may cause the skin to purge resulting in a break out. THIS IS NORMAL and does not mean you are having a reaction to the products. *Please click the yellow area and provide your initials here.

Consent for Chemical Peel

Please initial each section and sign the consent for aesthetic procedure.

Initial Here

Initial

I voluntarily consent to and authorize the licensed aestheticians to treat my condition. I understand the treatment may involve risks of complications or injury from both known and unknown causes and I freely assume these risks. Possible risks include but are not limited to scarring, skin redness, skin irritation, swelling, discomfort, tenderness, breakouts, dry skin, lightening of the skin (hypopigmentation), and darkening of the skin (hyperpigmentation). I understand these stated risks are those most relevant to an intelligent decision on my part, and the list of remotely possible material risks is nearly unlimited.I agree to adhere to all safety precautions and regulations during the procedure. Due to the nature of the treatment, exact results cannot be predicted and I acknowledge that no guarantees have been made to me as to the final or expected results that may be obtained. *Please click the yellow area and provide your initials here.

Initial Here

Initial

I understand that my responsibility, as the patient, is to follow the post-procedure care instructions and to maintain regular office visits that are critical to the success of the procedure. I agree that I will notify my Esthetician, as soon as possible, of any questionable conditions, complications, unusual symptoms or any questions that can arise. *Please click the yellow area and provide your initials here.

Initial Here

Initial

I have not used Retin-A for 72 hour and/or, Accutane in past year. I do not have active cold sores. I agree to avoid sun for 7 days. I agree not to wax, and/or undergo laser procedure for 7 days. I agree to follow the aftercare *Please click the yellow area and provide your initials here.

Please Enter Date *

Please enter valid date.

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