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: _________________________
Revue de presse du 1er juin Marianne Thyssen : « j’ai eu une attitude plutôt féminine » Marianne Thyssen est candidate au poste de Premier ministre. C’est l’information « campagne » de ce mardi donnée par tous les quotidiens. Ce n’est pas vraiment une surprise. Comme l’écrit le Soir , jusqu’à ce jour, elle ne le niait pas. « Je ne l’avais pas encore dit parce qu�
NATURAL ORGANIC DIABETES SOLUTION SUPPLEMENT Natural Organic Solution Supplements (NODSS) was born out of the conception of the legacy of my parents’ philosophy of using traditional medicine to care for all ailments. When I was diagnosed with diabetes with a 480 sugar level by Dr. Ronald of Brook Medical Center in Brooklyn I became challenged to fall back on my parents’ philosophy of applyin