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Consent Form
Consent Form
Blank Form (#3)
Appointment Date / Time
Personal Information
D.O.B
AGE
PHONE
ADDRESS
To perform the Skin Care treatment procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.
Have your ever had any skin treatments previously?
Yes
No
If yes, please specify
What would you like to achieve from your treatment today?
GENERAL INFORMATION
How would you describe your skin type?
Normal to dry
Normal to oily
Sensitive
Extremely dry
Extremely oily
Combination
Exposure to sun:
Never
Light
Moderate
Excessive
How do you prefer to get a skin tone?
Nothing
Sunbath
Tanning bed
Self-tanning
Do you experience:
Flakiness
Redness
Tightness
Excessive oily shine during the day
What type of foundation do you wear?
Liquid
Cream
Powder
None
How does your skin heal?
Fast
Scars
Pigments
Heals poorly
Do you bruise easily?
Yes
No
Any personal or family history of cancer?
Yes
No
Do you take care of your skin at home?
Yes
No
If yes, please describe
Have you used Retin- A in the past month?
Yes
No
Have you used Accutane in the past 12 months?
Yes
No
Have you used any oral/ topical skin medications in the past 6 months?
Yes
No
Do you have allergies to latex?
Yes
No
Do you have allergies to any skin care products?
Yes
No
If yes, please describe
Are you currently on any medications?
Yes
No
If yes, please describe
Men Only
Do you suffer from ingrown facial hair?
Experience razor burn?
Women Only
Pregnant
Trying to become pregnant
Not pregnant
Taking oral contraceptives
Taking hormone replacements
PLEASE, INFORM YOUR THERAPIST IF YOU HAVE ANY OF THE FOLLOWING:
Diabetes
Epilepsy
Deficient Immune System
Pregnancy
Breastfeeding
Electrical implants or pacemakers
Steroids, antidepressants, antibiotics and other medications
Recent surgery
Anticoagulant medicines such as warfarin or aspirin
Metal plates or pins
Chemotherapy/ Radiotherapy
Broken bones
Previous or recent treatments in the area
Please. check if you are affected by or having any of the following
Asthma
Skin disease
Eczema
Pins or plates
Fever blisters
immune disorders
herpes
chronic headaches
Hysterectomy
depression
high blood pressure
lupus
Sinus problems
anxiety
epilepsy
metal bone
Cardiac problems
hepatitis
pace maker
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