Skin Treatment Consent Form

First Name

Last Name

Phone Number

Address

How did you hear about us?

What is the reason for your visit today?

What special concern do you have?

How would you rate your skin?

Always burns, never tans - F1

Burns easily, tans slightly -F2

Burns moderately, tans gradually - F3

Seldom burns, always tans well - F4

Rarely burns, deeply tans - F5

Never burns, deeply pigmented - F6

Do you ever experience the following?

Flakiness

Tightness

Redness

Excessive oil shine during the day

Do you blush easily? What are the contributing factors?

Emotions

Foods

Temperature Changes

Other

Have you recently been on a hot vacation?

Have you previously had a professional peel / microdermabrasion / dermplaning or any other skin treatment carried out within the last 14 days?

Do you consider your skin to be sensitive/ resilient / unsure?

Do you frequently use tanning booths/ topical tanning products?

Do you have any BOTOX or fillers done? If so, when was your last treatment?

Have you recently had laser resurfacing or facial surgery?

Are you currently taking any medications or topical medications?

Have you ever taken Accutane medication? If yes, When?

Have you ever used a product that gave you a bad reaction?

Do you wear contact lenses? if yes please remove for treatment

Prior to receiving this skin treatment, I confirm that I have revealed all my health information honestly.

I understand that there are no guarantees with this or any other treatment

Treatment success is dependant on age, sun damage, smoking, climate, UV exposure, hormonal changes etc.

Skin peel: I may/may not peel and that each case is individual.

I understand that the amount of peeling does not correlate with degree of improvement.

I understand that to achieve maximum results, I may need several treatments.

Complications are rare but may occur. If this is the case, I will contact the technician immediately.

I have not had any type of treatment on the area to be treated in the last 14 days.

Daily recommended SPF 50 has been recommended to me and is mandatory.

I agree to minimise sun exposure, tanning beds & topical tanning products on the treatment areas while I am undergoing treatment.

I am not pregnant or nursing

I am not on any prescription topical retinoids

I am not taking Accutane

I understand that these treatments are cosmetic with no claims of them being medical

I agree to follow the aftercare instructions given and explained to me

If I do not follow the advice given and should I have any reactions I do not hold the technician or her business responsible.

I agree to follow the aftercare instructions given and explained to me

Please avoid the following to avoid complications

avoid all types of heat sources (exercise,saunas,hot tubs)for 2 weeks post treatment

your skin may be red for the first 48 hours post treatment

I hold harmless my skin therapist from any liability for any adverse reactions that may result from my treatment.

I have understood the above

I have been given the opportunity to ask all questions relevant to the treatment that I will be receiving.

I agree to all the above and agree to have this treatment preformed on me.

Your Signature

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Date