NEW PATIENT FORM: 

NAME:__________________________________        DATE:________________________

ADDRESS:STREET:_______________________CITY :_______________________STATE____

PHONE: HM__________________ CELL:__________________BUS:_____________________

EMAIL ADDRESS:___________________________________

Are you currently using any of the following products (Please circle) & Please list brand

Soap_______________Cleaser_________________Toner_______________________

Exfoliant/Scrub___________________Mask______________SunScreen_____________

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?

 

 

 

Patient signature_______________________________Date:______________________

 

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.

 

Patient Signature_______________________________Date:________________________

 

Parent Signature (Under 18)__________________________Date:_____________________