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Skincare Service

Medical Consultation Form


Consent Form

I acknowledge that this is an elective procedure at my request.

I Agree

I certify that I have listed all medications/medical procedures/medical disorders.

I Agree

I agree to follow all aftercare instructions to reduce the risk of post-procedural hyperpigmentation and potential scarring.

I Agree

I agree to contact the service provider with questions or concerns post-treatment.

I Agree

I confirm I have fully read, understood, and completed this Medical Conditions and Informed Consent Form and that the procedures such as Plasma Pen, Microneedling, Dermaplaning, Chemical Peels, etc, have been fully explained to me upon request.

I Agree

I understand that withholding any medical information may be detrimental to my health and safety both during and after my procedure, and I confirm that I have not withheld any medical information. I understand that if there is any change in my medical history, it is my responsibility to inform my technician.

I Agree

I understand for the desired outcome, several treatments may be required, and this has been explained to me. I also understand no guarantee has been given as to what the outcome of treatment may or may not be. By my signature, I affirm that I am at least 18 years old and freely give my informed consent to receiving treatment.

I Agree

December 8, 2023


First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I grant consent to photographs being taken BEFORE, DURING and AFTER my facial procedure. (optional)*
No
Yes
Are you pregnant or lactating? *
No
Yes
Do you wear contact lenses? (remove contacts if eyes are sensitive) *
No
Yes
Do you currently have a sunburn/windburn/red face? *
No
Yes
Are you in the habit of going to tanning booths? *
No
Yes
Are you applying any topical medications at this time? *
No
Yes

Which one(s)?
Are you currently using any topical Retinoid prescriptions (Retin-A®/ Renova®/ Differin®/ Tazorac®/ Avage®?) *
No
Yes

For how long? (Discontinue use 5-10 days before and after treatment) NOTE: consult your physician before discontinuing use of any prescription.
Are you currently using Accutane®? *
No
Yes

How long?

It’s OK to apply ONE layer of Sensi Peel®, Ultra Peel® II, Esthetique Peel® or Oxi Trio to skin that has been treated with Accutane®. Those who are currently taking Accutane® should be directed to their dispensing physician.

Have you had a chemical peel or any type of procedure with a medical device? (peels should follow injections by 2-5 days to prevent movement of the filler).*
No
Yes
Have you recently had facial surgery? *
No
Yes

Describe what type and how long ago:
Do you develop cold sores/fever blisters*
No
Yes
Are you allergic/sensitive to: (check all that apply)
milk
apples
citrus
grapes
aloe vera
aspirin
perfumes
latex
hydroquinone
mushrooms

If any other allergies, what?
Are you sensitive to alcohol-based products? *
No
Yes
Have you ever used any other products that caused a bad reaction? *
No
Yes
Are you taking any medication at this time? *
No
Yes
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Acne
Acne-scarred
Breakouts
Cysts
Dehydrated
Dry T/Zone/Combination
Eczema
Hyperpigmentation
Hypopigmentation
Large pores
Mature
Melasma
Milia
Normal
Oily
Psoriasis
Rosacea
Sun-damaged
Uneven
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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