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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

Fibroblasting with Plasma Pen cannot guarantee the exact outcome of this procedure, and results may vary from client to client.

I Agree

I certify I have received written post-treatment instructions

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 procedure known as Plasma Pen has been fully explained to me.

I Agree

I have had the opportunity to ask questions about the treatment and that my questions have been answered. I understand the importance of fully revealing my accurate and complete medical history. 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

June 28, 2022


First Client's Name

First Name*

Middle Name

Last Name*

Phone*
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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
First Client's Signature*
Second Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Third Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Fourth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Fifth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Sixth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Seventh Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Eighth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Ninth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Tenth Client's Name

First Name*

Middle 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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Additional Information

Emergency Contact


Name *

Relationship *

Phone: *
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
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 have permanent make-up?*
No
Yes

if so, to what areas of the face?
Do you currently have a sunburn/windburn/red face? *
No
Yes

Why?
Are you in the habit of going to tanning booths? *
No
Yes
Do you currently use or receive depilatories or waxing? (Discontinue use 7 days pre and post-treatment.) *
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

What strength?

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:

How long ago?
Have you recently had laser resurfacing?*
No
Yes

When?

What kind?

What type of work do you do?
Regular airline travel?*
No
Yes

How often?
Do you participate in vigorous aerobic activity or sports? *
No
Yes

What type?
Do you smoke or use tobacco? *
No
Yes
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
Natural eye color:
Blue
Green
Hazel
Gray
Lt.Brown
Med.Brown
Dk.Brown
Natural hair color:
Blonde Red
Lt.Brown
Med.Brown
Dk.Brown
Black
Gray/Silver
White
Skin tone:
Pale/White
Light
Medium
Reddish Freckled
Lt.Olive
Med.Olive
Dk.Olive
Lt.Brown
Med.Brown
Dk.Brown
Soft Black
Black
Do you consider your skin:
Sensitive
Resilient
Not sure?
Describe your skin (check all that apply):
Thick
Thin
Saggy
Firm
Normal
Dry T/Zone/Combination
Oily
Acne
Comedones/Blackheads
Milia
Cysts
Breakouts
Acne-scarred
Large pores
Small pores
Rosacea
Eczema
Freckled
Sun-damaged
Uneven
Mature
Wrinkled
Patchy
Melasma
Hypopigmentation
Psoriasis
Hyperpigmentation
Dehydrated

What is your daily care regimen

What are the cosmetic improvements you would like to see in your skin?
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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