Skin Care Intake Form
HydraFacial, Microdermabrasion and Peels:
Not for sensitive or rosacea-prone skin, or for women that are pregnant. I understand these treatments are resurfacing procedures that exfoliate the skin, the potential risks, and that results are not guaranteed. Most will see results immediately after treatment and feel smoother and more hydrated skin for one to four weeks with appropriate home care to maintain treatment results. I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for a minimum of 2 weeks pre- and post-treatment.
I agree that any questions I have regarding skin care treatments have been explained to my satisfaction, and that with any treatment certain risks are involved and that any complications from known or unknown causes could occur, and that possible side effects can include, but are not limited to: mild to moderate irritation, tightness, redness, tenderness, blemishes, or allergic reactions. Most side effects are temporary and will dissipate within 1-7 days. I will call to inform my esthetician of any complications or concerns I may have as soon as they occur. I understand that it is recommended prior to having a facial
have used Retin-A for 72 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment; waxing
have used Retin-A for 2 weeks or Accutane in 6 months. Due to skin being more susceptible after treatment, avoid sun exposure and use 30+ SPF sunscreen every day.
By signing below, I acknowledge that I have read the above information and give my consent to be treated. This consent form is valid for future treatment, but I will alert the staff is there are any future changes to my medical history. Thank you for completing this questionnaire; by doing so, your esthetician can give you the most personalized and effective treatment possible. Your privacy, including the information on this form is strictly confidential, and will not be shared without your permission.