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Facial Consent Form
Exact information is mandatory to evaluate my skin:
"
*
" indicates required fields
Name
*
First
Last
Email
*
Am I presently taking any medications?
*
Yes
No
Am I presently under the care of a doctor and/or dermatologist?
*
Yes
No
Am I taking Accutane, Retin A, Adapalene, Renova, or other prescription skin products?
*
Yes
No
Do I smoke?
*
Yes
No
Have I undergone radiotherapy or chemotherapy?
*
Yes
No
Have I undergone any of the following treatments: laser, medical dermabrasion, epidermabrasion, chemical peeling?
*
Yes
No
Do I sunbathe or use tanning beds?
*
Yes
No
Do I wear contact lenses?
*
Yes
No
Am I epileptic?
*
Yes
No
Do I exercise or play sports?
*
Yes
No
Am I pregnant, trying to become pregnant, or lactating?
*
Yes
No
Am I menopausal?
*
Yes
No
Do I suffer from any of the following: Heart-pacemaker, thyroid, hormonal imbalances, high or low blood pressure?
*
Yes
No
Do I suffer from: rosacea, eczema, psoriasis?
*
Yes
No
Please list any further conditions or areas of concern:
Soft Peel Consent Form
*
I hereby confirm the above information to be exact and understand that it will remain confidential.
I have been informed that secondary effects may occur as a result of my treatment, such as the following:
skin may be reddened following my procedure, however the redness will normally subside within 24-48 hours;
flaking of the skin may occur in the days following my procedure;
intense tingling, numbness, itchiness, and/or warmth may be experienced during my peeling procedure;
in rare cases a skin reaction may occur, consisting of but not limited to, intense redness, hives, swelling and rash.
These effects, if and when they do occur, typically disappear after 72 hours.
I have also been informed of the fact that treatment results may vary from person to person depending on their physiology and medical condition(s), which I have fully disclosed in the attached questionnaire.
I further acknowledge that it is recommended that skin should not be exposed to the sun for seven (7) days after the treatment. The application of a daily sun protection SPF 15 or higher is recommended.
The nature and choice of this treatment have been explained to me and I have been given satisfactory answers to my questions. I have read, fully understand, and agree to the above treatment information and recommendations and hereby waive any claim for damages of any kind whatsoever against the esthetician, Third Avenue Spa, and G.M. Collin as a result of the secondary effects that may occur after such a treatment.
Today's Date
*
DD dash MM dash YYYY
Signature
Comments
This field is for validation purposes and should be left unchanged.
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