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Pigmentation Saline Removal Consent Form


INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Pigmentation Saline Removal 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: August 1, 2026

I elect to receive the Saline permanent makeup removal Procedure(s) indicated in the next section. I understand there there are other options available for pigment removal. I have decided to decline those methods. I understand that more than one session may be necessary to achieve the best results, and that since the lightening of pigment in the skin is difficult and sometimes impossible, no guarantee is being made as to the quality of the outcome of the pigmentation removal Procedure(s).

Pre-Procedure and Aftercare Instructions: I have received, and will strictly adhere to, all pre-procedure and aftercare instructions. I understand that compliance with these instructions is crucial to support proper healing, and to mitigate the risk of any adverse outcome.

Summary of Risks: The nature and method of the proposed pigment (tattoo) lightening procedure have been explained to me including risks or possibility of complications during or following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Secondary infection in the area of the procedure may occur. Unwanted pigment may not be successfully lightened, and scarring as hyper- pigmentation or hypo-pigmentation, or other damage to the skin, which may be permanent, may occur.

Special Risk for Skin Types V and VI: I understand that there is a higher risk of hyper-pigmentation (browning) and hypo-pigmentation (whitening) for people with darker complexion, especially people with skin types V and VI. While this usually resolves within weeks, it can take as long as six months and, in rare cases, can be permanent.

I certify that this consent has been fully explained to me, that I have read the above paragraphs, and that I elect to receive the pigment lightening (permanent makeup removal) procedure(s) indicated above. I understand the permanence of the procedure(s) as well as the possible complications and consequences of the procedure(s). I consent to my photograph being taken before and after the procedure(s). 

Client Signature:

Date: August 1, 2026


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

First Client's Name
First Name*
Middle Name
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Third Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Fourth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Fifth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Sixth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Seventh Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Eighth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Ninth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Tenth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

Additional Information
Technician/Esthetician Performing Procedure:*
ID of Client or of Parent or Guardian (if Client is underage)
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Home/Cell Phone:
Work:
Preferred Contact:*

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s): 

Choose one*
I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. Fair skinned; light hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring? *
No
Yes

Please list the products you use regularly: 

Facial Cleanser
Moisturizer
Toner
Serum
Scrubs
Sunscreen
Retinol
Glycolic Acid
Enzymes
Peptides or Growth Factors

Cosmetic History 

What is the area to be treated?
How would you describe your skin?
Do you have any scars in or around the area to be treated?*
No
Yes
Are you prone to keloid or hypertrophic scarring? *
No
Yes
Are you prone or do you have tumors, growths, and/or cysts? *
No
Yes
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other:
If yes, when?
What body area(s)?
Have you had any other cosmetic surgeries/procedures?*
No
Yes
If yes, when?
What body area(s)?
Have you used Accutane in the past year?*
No
Yes
Are you using skin products with Retin A, glycolic acid, or other alpha hydroxyl acids? *
No
Yes

Health History

Have you had chemotherapy in the past 6 months?*
No
Yes
Do you have any of the following conditions:
Hepatitis (A,B,C,D)
MRSA
Eczema
Dermatitis
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
History of stroke
Heart disease and/or heart defects
Hemophilia
High blood pressure
Do you have any other health conditions not mentioned here? *
No
Yes

If yes, please list
Have you ever had a reaction at the dentist or any other time from numbing?*
No
Yes
Do you have any allergies to medications, food, latex, topical products, and/or other substances?*
No
Yes
Please list
Have you consumed drugs or alcohol in the last 24 hours? *
No
Yes
Have you undergone surgery in the last 2 weeks?*
No
Yes

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. 

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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