NEW PATIENT FORM:
PHONE: HM__________________ CELL:__________________BUS:_____________________
Are you currently using any of the following products (Please circle) & Please list brand
Moisturizer DAY___________Night_______________Serums_________________Other Skincare Products___________________________________________________
Are you currently taking any medication? YES _____ NO______Please List if Yes
Are you under the care of a skincare therapist, dermatologist, physician for your skin?
Are you using Retin A, vitamin A or any Acne medications? Yes________NO______________Please List:_______________________________________
Products containing Alpha Hydroxy Acids? YES______NO_________
Do you freckle or burn easily in Sunlight? Yes_______ NO_________
Have you had any of the following procedures? IPL/Laser Resurfacing YES____NO____
Dermabrasion YES_____NO_____ Botox YES____NO____ Collagen YES_____NO______ RESTALYNE/FILLERS YES______NO______
On a scale of 1- 10 how would you rate your stress level? _____________________
Do you drink coffee______Tea_______Sodas______ How many per day?_________
Do you smoke?YES_______ NO_______
Do you Drink Alchohol? YES__________NO_______ How many per day?__________
Are you on a special diet?_____________________________________________
Do you Exercise? YES_______NO______ How Often?________________________
Do you have any Allergies? Please list:_____________________________________
Do you break out or experience burning, itching, redness or irritation? YES___NO_____
What do you think is the cause?_________________________________________
Have you ever had a facial? YES_____NO_____ Type of Facial?__________________
Have you ever had a Facial Peel or Microdermabrasion? YES________NO________If YES, What type of Peel? Chemical or Enyzyme______________% of Peel?______________
PLEASE CIRCLE ANY OF THE FOLLOWING IF YOU HAVE EXPERIENCED :
Asthma Fever Blisters Hysterectomy Sinus Problems Eczema
Cardiac Problems Headaches (chronic) Immune Disorders Hepatitus
Depression Anxiety Skin Diseases Herpes High Blood Pressure
Epilepsy Lupus Metal Bone, Pins, Plates, Implants Pacemaker
What are your skin concerns?
What are your skincare goals?
What brings you in for a treatment today?
Are you open to prescribed Homecare Treatment to take care of healing and maintaining your skincare needs and goals?
Parent Signature (Under 18) _______________________Date:______________________
(New form )
CLIENT CONSENT FOR PROFESSIONAL EXFOLIATING PEEL
THOROUGHLY READ THIS CONSENT FORM, INITIAL EACH SECTION AND SIGN AND DATE THE BOTTOM. IF YOU HAVE ANY QUESTIONS, PLEASE DISCUSS THEM WITH YOUR SKINCARE PROFESSIONAL. Please fill this form out in addition to the new client form
______I have reviewed and completed the proper pre and post peel documents with my skincare therapist. I do not have any conditions that would prevent or requiree a doctor’s consent to have a professional exfoliating peel. I have reviewed the conditions that may suggest a reaction or slow healing and I am aware of this possibility.
______I acknowledge the possibility of allergic reaction and that my skin care therapist is not responsible for such a reaction or any medical care that may be necessary in the unlikey event of such reaction.
______I acknowledge that the use of home glycolic products for a minimum of two weeks and a professional exfoliating peel patch test do not necessarily negate the possibility of an adverse or allergic reaction.
______I will not pick, peel, or use an abrasive product on the treated skin area for several days following the professional peel treatment since these actions could potentially lead to an infection of pigmented areas.
______I understand that my skin may look red or darker, rough, and or dry for several days following the professional peel as the outer layer is sloughed off.
______I understand that I should avoid direct sun exposure, tanning booths for several weeks following peel and that I must protect my skin with UVA/UVB suncreen shield.
______I understand that I could potentially feel a slight tingling, burning, and prickling sensation during the prodedure and immediately following the procedure, this will subside gradually.
______I understand the above, and under these conditions, give my consent to have a professional Exfoliating Peel performed.
Parent Signature (Under 18)__________________________Date:_____________________