Advance Services Consent Form 

  • NEEDLING/ COLLAGEN INDUCTION THERAPY

  • RADIO FREQUENCY/ HIGH FREQUENCY

  • LIGHT- EMITTING DIODE (LED) THERAPY

  • ULTRA SONIC

  • CRYOGLOBE

  • HYDROFACIAL

  • MICROCURRENT

  • MICROCHANELLING WITH PROCELL

  • RADIO FREQUENCY

  • CHEMICAL PEELS 

  • AQUA DERMABRASION 

  • MLD 

  • SUAGRING 

  • WAXING 

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How do you describe your skin?
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Have you ever had any of the following injectables or implants? Circle One:
Do you have any of the following conditions: Please circle

Please answer the questions below:

Have you used Accutane in the past year?
Have you been treated for vascular veins, pigmented lesions or other unwanted lesions?
Do you have hyperpigmentation or hypopigmentation or marks after physical trauma?
Do you form thick or raised scars from cuts or burns
Have you had chemotherapy in the past 6 months?
Do you have a history of Erythema Ab Inge (EAI), a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat?
Do you have any health conditions not mentioned?
Have you consumed drugs or alcohol in the last 24 hours?
Have you undergone any recent surgeries?
Are you prone to keloid or hypertrophic scarring?
Have you had any needling or collagen induction therapy in the past?
Have you had any recent cosmetic surgeries/procedures?
Do you have any tattoos in the area to be treated?
Do you have moles/skin growths in the area to be treated?
Do you have high/low blood pressure?
Do you use any medications that cause light sensitivity?

Read the following information & possible risks.

- I understand that the use of Botox, Juvéderm, Restylane, and other injectables must be disclosed prior to treatment.

 

- I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.

 

- I understand that it is imperative to my health that I disclose all the information requested in the Client Profile/ Health History.

 

- I understand that microcurrent treatments involve conducting mild electrical currents through the body and that this brings some inherent risk.

 

- I understand that reactions are rare, but may include nausea, dizziness, and weakness. Some possible skin reactions including redness or irritation.

- I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications

Client Name (signature)
Esthetician signature

Thanks for submitting!