to the consent form

advertisement

NV Skin Therapy

Consultation Questionnaire

Name___________________________________________________________________________Date_____________________

Address__________________________________________________________________________________________________

Home Phone_________________________Work Phone_________________________Cell Phone_________________________

Email_______________________________Referred By:______________________________Date of Birth__________________

Medical Information

List all allergies (medicines, food, environment, etc.):_____________________________________________________________

List all medicines and vitamins you are currently taking:___________________________________________________________

Have you, or are you currently using:

Accutane ®

Retin-A ®

Benzol Peroxide

Other topical skincare medications:

____________________________________ How long?______________________ Last time used?______________________

Have you had any facial treatments?

Facials

Waxing

Chemical Peels

Microdermabrasion

Laser

Injectables

Facial Surgery? If yes, list type of treatment and dates:____________________________________________________________

Have you:

Used a tanning bed?

Experienced sunburn? If yes, how long ago and severity?__________________________

Check the following that apply to you:

Heart Problems

Diabetic

Cancer

Cold Sores

Psoriasis

Eczema

Smoke

High Blood Pressure

Hormone Imbalance

Pregnant

Claustrophobic

Wear Contact Lenses

Drink Alcohol

Please list any infectious diseases you may have:_________________________________________________________________

Please list any additional information that will help better serve you:_________________________________________________

Skincare Information

Please check the following that best describes your skin:

Dry

Oily

Normal

Combination

Sensitive/Redness

What concerns would you like to address about your skin?

Signs of Aging

Fine Line/Wrinkles

Acne

Redness

Broken Capillaries

Age Spots

Dryness

Sun Damage

Loss of Firmness/Elasticity

Dullness

Breakouts

Skin Discoloration

Large Pores

Blackheads

Other:_____________________________________________________

What would you most like to improve about your skin?____________________________________________________________

Check the following products you currently use:

Cleanser

Toner

Moisturizer

Serum

Exfoliant

Masque

Eye Care

Lip Care

Sunscreen

Other:___________________

Brands:___________________________________

Consent and Waiver for Chemical Exfoliation (Peel)

I understand that chemical exfoliation is a safe and highly effective treatment, but may cause some individual sensitivity and/or allergic reaction to one or more ingredients.

I understand that this treatment contains salicylic acid. I am not allergic to aspirin.

I understand that this treatment can not be performed on dermatitis; this includes rashes, open wounds, eczema & psoriasis.

I consent that one week prior to & after treatment, I have avoided electrolysis, waxing, depilatory creams & laser.

I consent that 48 hours prior to treatment and 24 hours after, I have avoided Accutane

®

, Renova

®

, Retin-A

®

, Tazorac

®

,

Differin

®

, Renova

®

, AHA/BHA, prescription Benzol Peroxide, or any exfoliating products that are drying or irritating.

I understand that during and after the process, there can be a warm, tingling, and sometimes burning sensation, as well as redness, pinkness and possible soreness, peeling and inflammation.

I understand that picking and pulling the skin may cause pigment or scarring.

I acknowledge that I have avoided sun exposure 24 hours before and after treatment and will use a daily SPF of 30.

Chemical exfoliation treatments addresses hyper-pigmentation, acne/breakouts, excessive oiliness, redness, dryness, fine lines/wrinkles, uneven skin texture, pore congestion/size, scarring, firmness, collagen production, radiance and glow.

I acknowledge that there are no guaranteed results, and could have an increase in uneven color or pigment.

I understand that to achieve maximum results, I may need several treatments and use home care products.

Disclosures

I confirm to the best of my knowledge, that the answers I have given are correct, and that I have not withheld any information that may affect the outcome of my treatment. This information is intended for each service received and is the guest’s responsibility to notify Nicole Visee of NV Skin Therapy of any changes to the above information.

I understand and assume all risks and will not hold Nicole Visee or NV Skin Therapy responsible for any services or outcomes/damages received at NV Skin Therapy.

This information is confidential and is necessary to evaluate and best meet your proper skincare treatment and at home regime.

Thank you for choosing Nicole Visee of NV Skin Therapy for all your skincare needs.

Guest’s Signature___________________________________________________________Date_______________________

_____

Download