Informed Consent For Facial Rejuvenation/Collagen Remodel
|
|
- Piers Pearson
- 5 years ago
- Views:
Transcription
1 Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser, which is used for dermatological procedures requiring soft tissue coagulation. More than one laser session may be necessary to achieve desired results. We are unable to treat clients that are on ACCUTANE and PHOTOSENSITIZING medications. Clients using ANTICOAGULANTS should be noted. The following problems may occur with treatment: Pain - Some people may feel some pain with this treatment, similar to snapping the skin with a rubber band. Reddening Laser treatment will cause a reddening of the area. The reddening will go away in one to two weeks. Swelling Laser treatment may cause swelling, which will usually go away in one week or less. Pigment Changes Although extremely rare, the treated area may heal with increased pigmentation (increased skin coloring). This occurs most often with darker colored skin and after exposure of the area to sun. You may have experienced this type of reaction before and noticed it with minor cuts or abrasions. The treated area must be protected from exposure to the sun (sunscreen for 4 weeks after treatment) to minimize the changes of too much pigmentation (increased skin coloring). However, in some subjects, increased skin coloring may occur even if the area has been protected from the sun. These spots usually fade in three to six months. In some cases, the pigment change is permanent. In some subjects who experience pigment alteration, the treated area loses pigmentation and becomes a lighter color than the surrounding skin. This type of reaction tends to gradually fade away and return to normal over a period of three to six months. Scarring There is a small chance of skin scarring, including abnormal raised scars. Scarring is a possibility because of the disruption of the skin s surface. Compliance with aftercare is crucial for the prevention of scarring.
2 Bleeding The laser treatment may cause some pinpoint bleeding which will probably stop within a few minutes without any lasting effect. The bleeding may not reach the upper level of the skin and may result in a dark reddening of the skin. The red color will darken to purple and purple-yellow and will disappear in one to two weeks. Blistering The laser procedure may produce heating in the upper layers of the skin resulting in blister formation. The blisters will go away within two to four days. Scabbing A scab may be present after a blister forms. The scabbing will disappear during the natural wound healing process of the skin. Infection If a blister or bleeding is present, an infection of the wound is possible. Any blistering or bleeding must be dressed with an antibiotic ointment and covered. An infection could last seven to ten days and could lead to scarring. It is important to follow all post-treatment instructions carefully. ACKNOWLEDGMENT: My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I Consent to the taking of photographs during the course of my laser therapy for the purpose of medical education. These photographs may be used for teaching or publication, as the case provider deems appropriate with a full respect to compete personal identity confidentiality. By putting my initial here AND my date of birth I do acknowledge that I do NOT want my photographs to be published, but it will be kept in my personal file for medical use only. -Initial -Date of birth: / / I hereby release Norma Khal, George Allen, MD and Silky Skin Laser Centers from all liabilities associated with the above indicated procedure. Client/Guardian Signature Laser Technician Signature Date Date
3 CLIENT INFORMATION & MEDICAL HISTORY In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. All information is strictly confidential. PERSONAL HISTORY Client Name Today s Date Date of Birth Age Occupation E mail: Home Address City State Zip Code Home Phone: ( ) - Cell ( ) - Work Phone ( ) - Emergency Contact Name and Phone How were you referred to us? Which of the following BEST describes your skin type? (Please circle ONE skin type) Type I Always burns, never tans, light color hair and eyes Type II Usually burns, tans with difficulty, light skin, light colored hair Type III Sometimes burns, but usually tans, darker eyes, slight coloring to the skin Type IV Rarely burns, tans easily, dark eye color, definitive darkening skin color Type V Very rarely burns, dark hair and eye color Type VI Very dark skin color, dark coarse hair, dark eyes Do you regularly use tanning salons or sun bathe? If yes; how often? Have you had any recent tanning or Yes sun exposure that changed the color of your skin? No Have you recently used any self-tanning lotions or treatments? Yes No Do you form thick or raised scars from cuts or burns? Yes No Do you have Hyper pigmentation (darkening of the skin) or Hypo pigmentation (lightening of the skin) or marks after physical trauma? Yes No If yes, please describe: * ONLY answer these questions if you are interested in laser hair removal Have you ever had laser hair removal? Yes No Have you used any of the following hair removal methods in the past six weeks? Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories Method Area(s) Method Area(s) Shaving Depilatories Tweezing Electrolysis Waxing Laser Other: Other:
4 MEDICAL HISTORY Are you currently under the care of a physician? If yes, for what: Yes No Are you currently under the care of a dermatologist? Yes No If yes, for what: Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? Yes No Do you have any of the following medical conditions? (Please check all that apply) Cancer Diabetes High blood pressure Herpes Arthritis Frequent cold sores HIV/AIDS Keloid scarring Skin disease/skin lesions Seizure disorder Hepatitis Hormone imbalance Thyroid imbalance Blood clotting abnormalities Any active infection Do you have any other health problems or medical conditions? Please list: Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced) Food Latex Aspirin Lidocaine Hydrocortisone Hydroquinone or skin bleaching agents Others: MEDICATIONS What oral medications are you presently taking? Birth control pills Hormones Others (Please list): Are you on any mood altering or anti-depression medication? Have you ever used Accutane? Yes No, If yes, when did you last use it? What topical medications or creams are you currently using? Retin-A Others (Please list): What herbal supplements do you use regularly? Female client: Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you using contraception? Yes No I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. Signature Date:
5 ERUBIUM AND ABLATIVE LASERS SKIN RESURFACING/AFTER CARE FORM The treated area is extremely delicate and must be handled with care during the initial healing phase (7-10 days). It may take a few weeks after bruising or scabs to disappear for you to notice fading of your lesions. Your response to treatment, therefore, will not be evaluated for several weeks, when the healing process is complete. 1. Apply Bacitracin, Polysporin, or Betamethasone ointment (not Neosporin). It is normal for the treated area to feel like sunburn for a few hours. You should use a cold compress wrapped in a soft cloth if needed. For minutes each hour for 4 hours. Avoid any trauma to the skin. Showers are permitted, but prolonged bathing is not advised. Gently pat dry with a soft cloth. Do not rub with a towel or washcloth because the area is extremely delicate while healing. Avoid strenuous exercise, or massage. 2. Avoid picking or pop any blisters, on the treated skin to achieve your best results. If any crusting, apply antibiotic cream. Some physicians recommend aloe vera gel or some other after sunburn treatment such as Desitin. Darker pigmented people may have more discomfort than lighter skin people and may require the aloe vera gel or an antibiotic ointment longer. Follow instructions as specified by your laser professional. 3. Makeup may be used after the treatment has quit swelling unless there is epidermal bleeding. It is recommended to use new makeup to reduce the possibility of infection. Keep the area moist. Any moisturizer without alpha-hydroxy acids will work. 4. Do not tan the laser-treated area 5. You will experience redness and bruising from five to fourteen days at the treatment. Avoid direct sun exposure and tanning beds for 1-2 months and throughout the course of the treatment so as to reduce the chance of dark or light spots. Use sunscreen SPF 25 or higher at all times throughout the treatment when going outside. 6. Avoid tweezing, waxing, bleaching or chemical peels during the course of the treatment. Do not use any irritants such as Retin-A, Benzoyl Peroxide or astringents. 7. If work on the leg has been done, wear compression stockings for 48 hours and then during the day while on feet for up to two weeks. 8. Call your physician s office with any questions or concerns you have after the treatment.
INFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.
INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and
More informationHair To Bare South. Client Name: Date:
Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of
More informationWelcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!
Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour
More informationInformed Consent for Light Energy Tattoo Removal
Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff
More informationEast Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
More informationMenter Cosmetic Institute 3900 Junius Street, Suite 105 by Texas Dermatology Associates Dallas TX, (972) Ext. 255
PRECAUTIONS TO CONSIDER BEFORE FRAXEL TREATMENTS SIX TO TWELVE MONTHS BEFORE TREATMENT: Stop use of Accutane TWO WEEKS BEFORE TREATMENT: Stop use of all Retinols - Retin-A, Tazorac, anti-aging products
More informationBeautiful You LLC. Laser Hair Removal Pre/Post Treatment Care
Beautiful You LLC Laser Hair Removal Pre/Post Treatment Care Pre-Treatment Instructions Avoid deep tanning, including tanning beds and tanning creams, 2 weeks before and 1 week after treatment. If you
More informationLaser Hair Removal. Name Date of Birth. Address City State Zip. Home Tel. # Cell # How Referred
Laser Hair Removal Name of Birth Address City State Zip Home Tel. # Cell # Email How Referred Ethnic Background Previous Treatments Year Area(s) Hair and Skin Question - DO NOT use White, Jewish or Caucasian.
More informationPre & Post (BBL)Laser Hair Removal Treatment Instructions
Pre & Post (BBL)Laser Hair Removal Treatment Instructions Pre-Treatment Recommendations: Apply SPF 30 (or higher) sunblock at all times on areas to be treated that are exposed to any sun. Shave the area
More informationForename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM
Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM 1 SOPRANO ICE SHR PERSONAL INFORMATION Gender: Male/Female Date of birth.age. Home address..postcode.. Telephone..Mobile.. Email address.. GP
More information513 Maple Ave West, Vienna, VA
CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you
More informationEast Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
More informationNEW CLIENT FORM. Address: City: State: Zip: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type seems to best describe your skin
OREGON LASER & WELLNESS CENTER 4370 SE KING ROAD SUITE 105 MILWAUKIE, OR 97222 PHONE: 503 305 7704 or 971 263 7679 Date: Name: NEW CLIENT FORM Address: City: State: Zip: Email: Home Phone: Work Phone:
More informationMaya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:
Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your
More informationHEALTH HISTORY INFORMATION
HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More informationLaser Skin Resurfacing what to expect
Laser Skin Resurfacing what to expect Laser skin resurfacing is a treatment to reduce facial wrinkles and skin irregularities, such as blemishes or acne scars. The technique directs short, concentrated
More informationLASER TREATMENT INFORMED CONSENT
LASER TREATMENT INFORMED CONSENT PRINT NAME: BIRTHDATE: / / DATE: The following Larson Modality Services are performed by trained, certified, licensed personnel and healthcare providers of Margaret L.
More informationIPL CONSULTATION AND LIABILITY DOCUMENTATION
Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of
More informationAREA OF BODY TATTOO IS SITUATED?
CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo
More informationHEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other
HEALTH HISTORY To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can. PERSONAL INFORMATION Name _ Date DOB Age Address _ City State
More informationHISTORY CARD. [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet
HISTORY CARD Name: Date of Birth: / / Street Address: City: State: Zip: Telephone: (Home) Email: MEDICAL HISTORY Are you under a doctor s care: Yes [ ] No [ ] Please list any recent surgeries/injuries:
More informationTouch Up-Color Refresh Policy
Touch Up-Color Refresh Policy All Full Price New Procedures clients receive one Follow up visit for $50 with your initial price per procedure. You must wait at least 30 days before you can be touched up.
More informationWelcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine
MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce
More informationClient Medical History Form
Client Medical History Form Date Birth Date Age DL or ID# Name: Address City State Zip Phone Email Emergency contact person Phone Do you presently have or previously had any of the following: (Circle yes
More information12 FEBRUARY 2016 LNEoNLiNE.com
12 FEBRUARY 2016 LNEoNLiNE.com Delicate DEALINGS UNDERSTANDING SENSITIVE SKIN BY KRIS CAMPBELL S ensitive skin is a condition the skin care professional sees every day in the treatment room. In a study
More informationMicroblading Consent and Release Agreement
Microblading Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a Microblading semi-permanent make up application. If
More informationPersonal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
More informationContraindications Pre and Post Instructions
Contraindications Pre and Post Instructions **VERY IMPORTANT---PLEASE READ** **It is very important you follow these rules as medical conditions can affect the outcome of your eyebrows. Please notify me
More informationConsent and Release Agreement
Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you
More informationPre Treatment Advice and Procedures
Pre Treatment Advice and Procedures 1. Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
More informationClient Information Sheet
Esthetic Laser Clinic 8381 Old Courthouse Road Suite 300 Vienna, VA 22182 (703) 288 0085 www.elaserclinic.com Client Information Sheet Last Name First Name: Address City State Zip Code D.O.B. (MM/DD/YY)
More informationClient Medical History Form
Client Medical History Form Date Birthdate Name Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES or NO) YES NO History of MRSA YES NO Botox
More informationCLEAR TOE INTAKE INFORMATION
CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More informationCOSMETIC INTEREST QUESTIONNAIRE
COSMETIC INTEREST QUESTIONNAIRE Patient Name: Date: General appearance or products of interest to you (please check all that apply). Skin care consult Facial veins Neck elasticity Skin care products Facial
More informationCLIENT HISTORY. May we contact you at these numbers?
CLIENT HISTORY Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Street City State Zip Business Phone: May we contact you at these numbers? Other ID: Referred by: Emergency Contact:
More informationPre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser. James A. Rieger, MD (316)
Pre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser James A. Rieger, MD (316)-652-9333 You have scheduled a delicate cosmetic laser procedure. The following information
More informationNEW CLIENT GENERAL INFORMATION FORM
NEW CLIENT GENERAL INFORMATION FORM First Name: Last Name: Email: Date of Birth: Occupation: Home Phone: Cell Phone: Carrier: Gender: Female Male Preferred Staff Gender: Female Male Preferred Staff Member:
More informationClient Questionnaire Skin & Health
Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby
More informationPre-Treatment Advice and Procedures
1 Client copy Pre-Treatment Advice and Procedures Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty"
More informationClient Medical History Form
Client Medical History Form Today s Date: Birthday: / / Age Name: TXID# Address: Phone: Email: Tattoo Area: Eye Brows (Micro-Blading) Brand of Ink: Bio Touch Pure / / / Emergency Contact: Phone: Do you
More informationNewport Cosmetic Center
Shirin Afrasiabi, M.D, Inc. 2301 Newport Blvd, Costa Mesa, Ca 92627 (949) 548-5700 Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and
More informationMicroblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address
Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES
More informationDate: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian
Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic
More informationBrilliant Bodywork. Name: Date: Address: City: State: Zip: Home Phone: Business Phone: Cell Phone: Date of Birth: address:
Brilliant Bodywork Skin Care History Questionnaire and Waiver Please answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle,
More informationSKIN CARE INTAKE (SCI)
SKIN CARE INTAKE (SCI) Patient Name (Print) Today s Date Street: Date of Birth Apt # Home Phone City, State Zip Code Cell Phone E-Mail How did you hear about REDBAMBOO? Walked by Twitter Groupon Magazine
More informationSTATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow
More informationChameleon Medical Spa NEW CLIENT HISTORY
NEW CLIENT HISTORY This information will allow your professional skincare specialist to provide the optimum products and services. First Name: Last Name: Date: Birth date: Address: City: State:_ Zip code:
More informationCLINICAL FORMS AND CHARTING
CLINICAL FORMS AND CHARTING CLINICAL Lira Clinical forms to help you chart, analyze and evaluate your client for a successful skin care plan. 110 110 NAME TREAMENT DATE PROFESSIONAL RESURFACING TREATMENT
More informationPre- & Post Hair Removal Instructions and Home-Care Regimen
Pre- & Post Hair Removal Instructions and Home-Care Regimen Pre-Hair Removal Regimen: Avoid sun exposure or tanning beds to the area being treated. The laser may be less effective on burned or tanned skin.
More information5504 Backlick Road Springfield, Virginia
Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone email How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1
More informationCLIENT QUESTIONNAIRE
CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone
More informationNew Patient Registration
New Patient Registration Today s Date: Social Security Number: Name: Last First MIddle How do you like to be addressed: Date of Birth: Address: Street City State Zip Email Address: Preferred Contact Number:
More informationCOSMETIC LASER AND AESTHETICS CENTER
COSMETIC LASER AND AESTHETICS CENTER PERSONAL INFORMATION Please complete the following: Date: Name: Date of Birth: Home Address: City: State: Zip: Home Telephone: ( ) Cell: ( ) Work Phone: ( ) Email This
More informationCLIENT QUESTIONNAIRE TODAY S DATE: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) I AM INTERESTED PRIMARILY IN:
CLIENT QUESTIONNAIRE TODAY S DATE: NAME: DATE OF BIRTH: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) Fine Lines/Wrinkles Dark Circles Puffy Eyes Blotchiness/Discoloration Uneven Skin Tone
More informationSOUTH BAY LIPO LIGHT
SOUTH BAY LIPO LIGHT FACIAL TREATMENT INTAKE FORM Your success is our #1 priority. PLEASE ANSWER ALL QUESTIONS Help us to help you achieve success by filling out this questionnaire as completely as possible.
More informationClient Consultation. Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Referred by:
Client Consultation Date: Name: Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) E-mail address: Married: Single: Employer: Occupation: Does your job require that you work outdoors?
More informationLaser Resurfacing Post Op
Laser Resurfacing Post Op RECOVERY TIMETABLE: Approximate recovery after laser resurfacing surgery is as follows: DAY 1: Return home. keep treated areas moist by reapplying ointment or vaseline frequently.
More informationPre-Treatment Advice and Procedures
Pre-Treatment Advice and Procedures 1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
More informationMedication Name Reason Taken Dosage Last Date Taken
CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:
More informationCLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
More information513 West Maple Ave West, Vienna, VA
`MEDICAL HISTORY FORM Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male Family Doctor: Phone: Pharmacy: Phone: Emergency Contact: Phone:
More informationSkinCeuticals Flagship Advanced Medical Spa
SkinCeuticals Flagship Advanced Medical Spa 570 Long Point Road Mt Pleasant, SC 29464 843-881-0320 Table of Contents Spa Personnel Platelet Rich Plasam (PRP) Treatment Instructions TruSculpt Treatment
More informationCLIENT QUESTIONNAIRE
CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone
More informationBrow and Beauty Bar - Permanent Makeup
General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises
More informationPermanent Makeup Before & Aftercare Instructions. Permanent Makeup by Michelle Louise
Permanent Makeup by Michelle Louise Permanent Makeup Before & Aftercare Instructions IMPORTANT INFORMATION This document contains important information. Please read it carefully. www.michelle-lousie.com
More informationClient Intake Form. Name: Date: Address: City: ST: Zip: Phone:
Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
More informationWould you like to receive informational updates, specials and newsletters? Yes No
Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive
More informationMassey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:
Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.
More informationIntake Form Chemical Peels, Microdermabrasion, and Facials
Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages
More informationPermanent Cosmetics Contraindications
Permanent Cosmetics Contraindications under 18 years of age diabetes pregnant or lactating women glaucoma skin diseases such as psoriasis, eczema and undiagnosed rashes or blisters on the site that is
More informationClient Training Guide
Imagine never having to shave ever again Client Training Guide CONFIENT IMAGE CHEZ FRANCE (905) 931-0686 confidentimage@cogeco.net (905) 931-0686 confidentimage@cogeco.net - 1 - LASER HAIR REMOVAL Client
More informationPersonal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
More informationPre Wax Prep. PLEASE DON T SHAVE! You re coming in for a waxing service, and if your hair is
Pre Wax Prep Please bring a list of medications that you are taking to your appointment, and keep me appraised of any changes to your medications during subsequent appointments. There are several medications
More informationPermanent Makeup Intake Form
Permanent Makeup Intake Form Artist Information (the Artist ): Chrystal Ladouceur 1530 McTavish Road, North Saanich, B.C., V8L 5T3 Client Information (the Client ): First Name Email Mobile Phone Address
More informationPatient Contact Information. Name. Home Address. City State Zip
Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive
More information(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER
INFORMED CONSENT FOR DERMAL FILLER (Injection of collagen, hyaluronic acid or other filler materials) INTRODUCTION Dermal fillers are injected just under the skin s surface in order to temporarily correct
More informationTimeless Makeup, LLC
Timeless Makeup, LLC CLIENT REGISTRATION (Please complete all blanks) I. CLIENT INFORMATION Name Date Address City Zip Phone number Email address Type of work Ethnicity Date of birth What was your hair
More informationAddress City State ( ) 32 YES NO. 33 YES NO Are you undergoing radiation or chemo-therapy treatment? 39 YES NO 45 YES NO
CLIENT HISTORY FORM Print Name Location of Service: Email @ Birth Date Age Gender Female Address City State / Male Emergency Contact Name Home Phone ( ) Cell Phone ( ) Today s Procedure Description: Eyebrows
More informationAPPOINTMENT POLICY. Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy.
APPOINTMENT POLICY Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy. 1. One consultation visit is free of charge. A 24 hour
More informationPRODUCT YES / NO BRAND NAME PRODUCT NAME FREQUENCY OF USE
Consultation Form Today s Date: Name: Your Birthday: Spouses Name: Spouses Birthday: Anniversary: Address: City: St: Zip Home Phone: Office Phone: Cell Phone: Email Address: Purpose for visit: How did
More informationibrow Studio Client Information Packet
ibrow Studio Client Information Packet Thank you so much for trusting me with your beautiful face! Prior to booking an appointment, we ask that all ibrow Studio clients read and review the information
More informationPatient Information. M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Whom may we thank for referring you?
Today's : First Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Patient Information Last Name Email: Primary Care Physican:
More informationSkin Reactions from Radiation Treatments
Skin Reactions from Radiation Treatments Skin reactions are a common side effect of radiation treatments. They are caused when repeated doses of radiation pass through the skin. Skin reactions occur within
More informationAesthetic Patient Form
Aesthetic Patient Form Name: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell: Age: Date of Birth: Occupation: Email: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type that seems
More informationEverything you need to know about TATTOO REMOVAL
Everything you need to know about TATTOO REMOVAL LASER TATTOO REDUCTION Tattoos are meant to last forever, but sometimes it would be good if they didn t! Whether you wish to erase a mistake or fade a tattoo
More informationCLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age Have you received chemotherapy
More informationElite Beauty Essentials
Elite Beauty Essentials P E R M A N E N T M A K E U P W I L L N O T B E PERFORMED IF YOU ARE PREGNANT, NURSING or TRYING!!! NO EXCEPTIONS! If you are late for your appointment you will be rescheduled.
More informationImbue Aesthetics & Wellness PATIENT REGISTRATION FORM
Today's Date Legal Name Marital Status Sex DOB Age Mailing Address Preferred Phone Number Email Do we have your permission to add you to our email list to receive newsletters and promotions? YES NO Emergency
More informationMicroblading. More information can be found at the Society of Permanent Cosmetic Professionals.
Microblading (eyebrow tattooing, eyebrow embroidery, microstroking, micropigmentation, dermal implantation, permanent cosmetics, feathering eyebrows cosmetic tattooing) Any time color is placed into the
More informationArch Envy Eyebrow Consent and Release Agreement
Arch Envy Eyebrow Consent and Release Agreement This form is designed to give informa 椀爀 on needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery semi permanent make up
More informationVENUS BEAUTY LOUNGE. Before Your Microblading Session
Great microblading is not a beautiful result directly after treatment. It is a crisp, natural, long-lasting result once healed. Aleksandra Maniuse-Founder Deluxe Brows Microblading is a manual technique
More informationMicropigmentation (Semi-Permanent Makeup) Informed Consent
Micropigmentation (Semi-Permanent Makeup) Informed Consent The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent
More informationAreas of Concern. Patient s Name Last First Date
Areas of Concern What are your main concerns for today s visit? Please check the problem areas that concern you. Include anything you wish to discuss, even if it is not the main reason for your visit.
More informationGENERAL CONSENT AND PROCEDURE PERMIT FORM
GENERAL CONSENT AND PROCEDURE PERMIT FORM Please read this form fully and sign at the end. If you are unsure about a particular detail of the form, please speak to your therapist. If unforeseen condition
More informationConsultation Form: Coffeeberry Peel
Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice
More informationPatient Instructions for Fractional CO2 Laser Resurfacing
17560 South Golden Road, Suite 100, Golden, Colorado 80401 Patient Instructions for Fractional CO2 Laser Resurfacing Fractional laser resurfacing has revolutionized the treatment of fine lines and wrinkles,
More informationVICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.
MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED
More informationCLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Phone : Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy or radiation
More informationCLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
More informationCOLORADO AESTHETIC CENTER
COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better
More information