Skintelligentsd.com

CLIENT CONSULTATION AND RELEASE FORM
Please read carefully, complete, sign and date this form prior to your treatment.
Name: __________________________________ Phone: (______) __________________
Address: ________________________________________________________________
City: _________________________________ State: ______ Zip: __________________
�HYDRAFACIAL �MICRODERMABRASION �BLUE LED LIGHT THERAPY �ULTRAMAX
�RED LED LIGHT THERAPY �LYMPHATIC/MASSAGE THERAPY
SECTION 1: MEDICAL INFORMATION
• Do any of the following conditions relate to you?
YES NO
��Accutane or other similar medication
��Allergies
��Autoimmune disease, HIV, lupus, hepatitis
��Blood thinners – Heparin, Coumadin, Warfarin, etc.
��Breast feeding, pregnancy
��Cancer or post-cancer treatments
��Cardiovascular problems
��Cold sores or fever blisters without pre-medication
��Cortisone or steroid injections
��Cosmetic injections, fillers or implants, (i.e. Botox®, collagen)
��Eczema, psoriasis
��Enlarged or painful glands
��Epilepsy
��Facial waxing services w/in 7-14 days
��Heart ailment
��Hypertension/high blood pressure
��Inflammatory conditions
��Irregular, pigmented moles, warts or growths, unidentified facial growth or mark
��Keloids, pigmented scars, icepick scars, new scar tissue
��Laser procedures, chemical peels, dermabrasion, microdermabrasion
��Light sensitive medication
��Loose, thin, aged skin
��Lymphatic disorder, inflammation of lymph vessels, lymphedema
��Medication:
��Pacemaker or metal implants
��Phlebitis, varicose veins
��Recent accident or serious injury
��Recent surgical or dental procedure
��Rosacea, telangiectasia/couperose
��Retin-A, Retinol
��Skin abrasions or lesions
��Stage III or IV acne
��Skin-lightening or bleaching agent
��Sunburn
��Swollen or infected tonsils
��Thyroid conditions
(Continued on next page)
Rev 8/28/08
Courtesy of Edge Systems Corporation �2007 Edge Systems Corporation �www.edgesystem.net
��Type I diabetic
��Under medical care for an existing or suspected condition or disease
��Viral infection, influenza
��Other contraindication at discretion of skincare technician or medical practitioner:
• My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyper-pigmentation,
scarring,
etc.) ______________________________________________________________________________
___________________________________________________________________________________
• Specify your areas of concern (i.e. eyes, forehead, etc.)
_______________________________________
____________________________________________________________________________________
SECTION 2: CLIENT CONSENT FORM
(Initial each acknowledgement line below)
1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last
12
months. _____(initial here)
2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or
pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used
each
day for two days before, same day, and two days after any aggressive facial exfoliation treatment.
_____(initial here)
3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade.
Pigmentation
may improve or darken with successive treatments. I acknowledge the need for proper skin care home
regimen. _____(initial here)
4. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling
which
usually dissipates within 72 hours depending on skin sensitivity. _____(initial here)
5. I acknowledge that if I fail to use a minimal sunscreen (SPF 15), I am more susceptible to sunburn, skin
damage& hyperpigmentation. _____(initial here)
6. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims
have
been expressed or implied. _____(initial here)
7. I acknowledge that I should avoid use of glycolic products for 2-4 weeks following the treatment.
_____(initial
here)
8. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by
my
medicalor �skincare professional during and following the treatment. _____(initial here)
9. I acknowledge that I am not pregnant/lactating. _____(initial here)
10. I hereby agree to have the treatment performed and agree to follow all pre and post treatment
instructions.
_____(initial here)
11. I acknowledge that I have answered all questions truthfully and completely. _____(initial here)
12. I release the instructors, management and staff of Edge Systems Corporation and
__________________________, from any and all liability associated with any injuries and/or current or
future
conditions resulting from the skincare procedures or products. _____(initial here)
13. I consent to the use of my before, during and after facial procedure photographs for education,
promotion or
advertising purposes. _____(initial here)
Client Signature: ____________________________________________ Date:
___________________________
Skincare Practitioner Signature: _________________________________ Date:
_________________________

Source: http://skintelligentsd.com/wp-content/uploads/2013/06/Client-ConsentRelease-Form-for-HydraFacial-MD.pdf

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