CONSENT TO MICRODERMABRASION TREATMENT PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS BY SIGNING BELOW I, __________________________________ , acknowledge and agree to hold Alamo Hills Advanced Aesthetic & Laser Center and any of its employees harmless against any and all liability and claims for any injuries or any other occurrence
Microsoft word - client intake form2 - bodywrap and facial.docx
Please complete the following information if you are receiving a Facial, Body Wrap or
Skin Care treatments:
1. Do you have any special skin problems pertaining to your face or body? If yes, please specify: _________________________________________________________________________ 2. Do you suffer from any of the following: Acne – where? _____________________________________
Other resurfacing treatments: ______________________________________________________If yes, were they in a medical setting? 2. Are you taking or using, or have used any of the following prescriptions or medications in the last six months? Other prescription skin products: ___________________________________________________ 3. Are you currently using any products that contain the following ingredients? 4. Are you allergic to any topical substances? _______________________________________________________________________________
1. Do you ever experience these conditions on your skin? Flakiness Tightness Obvious Dryness Where? When? _____________________________________________________________________________ Capillary Activity:
1. Do you burn easily in moderate sunlight?
1. How late in the day do you experience oily shine? __________________________________________________ 2. Where and when do you experience skin breakouts? ________________________________________________
1. Do you ever experience a burning, itching sensation on your skin? Where/When? ______________________________________________________________________________ 3. What type of massage pressure do you prefer? 4. Have you ever had a reaction to any of the following? Other: ___________________________________________ 1. Following a waxing treatment have you experienced any of the following? 2. Do you have any skin sensitivities, irritants or rashes? ___________________________________
NOTE: Do not expose skin to the sun/indoor tanning for at least 48-hours after the waxing service.
1. Are you pregnant or trying to become pregnant?
1. What are your skin care goals? ________________________________________________________________ __________________________________________________________________________________________ 2. What results would you like to focus on today? ____________________________________________________ __________________________________________________________________________________________ Skin Examination:
(For Esthetician Use only)
Sup. Wrinkles: ____________________ Deep Wrinkles: ____________________ Skin abnormalities: _________________________________________________________________ Scars: _____________ Date: ____________ Size: _______________ Color: _______________ Pigmentation Spot: _________ Size: ____________________ Color: _____________________ Professional Observation: _________________________________________________________________ ______________________________________________________________________________________
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