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Skincare Intake and Consent for Treatment

 

Welcome to Luz!  This general information and consent form provides the necessary information to assist patients in making informed decisions about their skincare journey.  This includes, but not limited to, facials, extractions, exfoliation, chemical peels and the use of topical skin care products.

Our facials and peels improve overall skin function and enhance appearance based on the principals of controlled wound. Controlled wounding of the skin helps to stimulate cell renewal and regenerate a healthier epidermis and dermis.

To ensure best results, it's important you share with us any prescribed medications you are taking, any recent laser or peels you may have done in the last couple of weeks and/or any injectables you've had including Botox or filler.  


I've not had any prescription creams, done peels or recent injectables in the last 2 weeks.

General risks, side effects, and complications with Skin Care Treatments include, but are not limited to:

  • Prolonged erythema (redness) or edema (swelling) from peels or exfoliation
  • Allergic reactions to any products
  • Blistering from any topical products 
  • Visible flaking/peeling
  • Hyperpigmentation or hypopigmentation 
  • Abrasion (superficial cut) or temporary lines and streaking may occur with micro dermabrasion
  • Acne outbreak or the activation of recurrent viral infections such as herpes simplex may occur
  • Infection or scarring

The risks of complications are higher for patients with darker skin types due to melanin production, the skin's way of protecting itself.  Please initial that you understand the risks of doing any kinds of skincare peels or deep exfoliation.  


Most people heal without any problems. However, here are some problems that you may encounter if you have any active viruses in your body: If you are prone to getting fever blisters (herpes simplex) then you could develop a herpes infection. You will notice that the skin becomes thickened and has a different feel. In fact you should recognize the familiar symptoms of herpes. If so then apply a suitable anti herpetic preparation prior to your facial. 

 


You might notice small white dots appearing on the skin after your facial. These might be simple little retention cysts (Milia) or they could be slightly infected areas. Purging and inflammation can sometimes occur after a facial.  If that happens, carefully but firmly wipe them away and apply an antibiotic lotion. It is a good idea to follow up with us and consult your doctor about this, if it persists.

 


It's also important to sleep on clean sheets after a facial, to avoid bacteria build up or infection.  I understand that I need to sleep on clean sterile sheets or a clean towel the first 48 hours after treatment to avoid risk of any infection.


 

I understand that it is not possible to predict any of the above side effects or complications, and results are not guaranteed. I have fully read this consent form and understand the information provided to me regarding the proposed procedures, and I have had all questions and concerns answered to my satisfaction.

March 25, 2026

 


First Client's Name
First Name*
Last Name*
First Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Tell us about your skin...
What is the most important improvement you'd like to see in your skin?

Describe your daily skin care routine...
Please check if you've had/have any of the following... if none, please select "Not Applicable"
Accutane (Less than 6 months)
Actinic (solar) keratosis
Active Bacterial or Fungal Infection
Blood Clotting Disorders
Cardiac Abnormalities or Disorders
Chemo therapy or radiation (less than 6 months)
Collagen Vascular Disease
Herpes Simplex
History of diabetes
History of eczema
Immune Suppression Disorder
Keloid scar
Psoriasis
Raised moles on the face/neck/chest
Retin-A use (less than 2 weeks ago)
Scars (less than 6 months)
Scleroderma
Warts on the face/neck/chest
None applicable
Have you had a chemical peel within the last month?*
No
Yes
Do you experience acne breakouts?*
No
Yes
Do you experience oily shine throughout the day?*
No
Yes
Do you ever experience a burning, itching sensation on your skin?*
No
Yes
Do you ever experience flakiness and/or tightness?*
No
Yes
Do you sunbathe or use tanning beds?*
No
Yes
Do you have a tendency to redness?*
No
Yes
Have you ever had an allergic reaction or sensitivity to a skin care product?*
No
Yes
If yes, please list the product and reaction.
Within the last 12 months, have you been under the care of a dermatologist?*
No
Yes
If yes, what for?
Have you had or do you have any health problems?*
No
Yes
If yes, please specify...
Do you have any specific skin disorders pertaining to the area to be treated?*
No
Yes
If yes, please specify...
Do you or have you ever smoked?*
No, I do not and have never smoked
Yes, I currently smoke
Ex-smoker
Skin Care Products

What products are you currently using on your skin? Please list the name and how often you use the following... Cleanser, Toner, Exfoliator, Moisturizer, Serum, Eye Products. Please list any by name.
Are you currently using any products that contain the following ingredients? Select all that apply.
Glycolic Acid
Lactic Acid
Hydroxy acids
Vitamin A derivatives (Retinoid, Retin-A, Retinol)
None of the above
How much water do you consume daily?
Do you eat a balanced diet?*
No
Yes
Are you allergic to silver cream or sulfur?*
No
Yes
On average, How many alcoholic beverages do you consume weekly?*
Please select "Yes" to confirm you understand and agree to the following statements.
Use of Vitamin A and/or C products are often contraindicated (not advised) when receiving laser, micro-needling or Microdermabrasion. I agree to avoid these products for 2 weeks before AND after my treatment unless my provider directs otherwise.*
No
Yes
I understand that in order to achieve optimal results pertaining to my treatment today, I am expected to follow up at home by using appropriate and quality products. I will consult with my care provider and follow all after care instructions.*
No
Yes
No guarantee can be given to me as to the condition of my skin or degree of improvement expected following treatment. I understand skin care treatments are on going and often require multiple treatments to achieve optimal results.*
No
Yes
I am NOT pregnant or lactating.*
No
Yes
I understand that daily use of broad spectrum sunscreens are crucial to achieving my desired result and agree to apply and reapply SPF following my treatment.*
No
Yes
I understand that in rare cases, allergies or sensitivities have been reported to products used in aesthetic treatments. I am NOT allergic to progesterone based products, lactose or latex.*
No
Yes
I understand that I need to sleep on clean sheets or a clean towel the first 48 hours after my treatment to minimize the risk of infection.*
No
Yes
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 Date of Birth*
Date of Birth
Information
Please select all medical conditions/disorders
AIDS or HIV
Autoimmune disorders
Bleeding or clotting disorders
Cancer
Cardiovascular disorders
Cosmetic implants
Endocrine disorders
Genital herpes or cold sores
History of seizures
Hormonal imbalances
Keloid (hypertrophic/raised) scars
Lupus
Neurological disorders or epilepsy
No known medical conditions
Pacemaker

Please provide more details regarding selected medical conditions. Are you currently under the care of a doctor/specialist? Do you take any medications for your condition? (name and dosage) If none, leave blank.
Are you currently on any medications? (prescription, herbal supplements, and or vitamins?) If "yes" please list all medications, dosage and reason for taking
Please list any and all known allergies or allergic reactions
Within the last month, have you used any topical Vitamin A derivatives (prescribed or over the counter)? (tretinoin, Retin-A, Retinol)*
Have you ever been prescribed Accutane? If so, when was the last time you took it?*
Have you waxed, lasered, peel treated or had injections in the last 14 days anywhere on your face, neck or chest?
Face
Neck
Chest
None
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had sun exposure/got tanned?*
I'm interested in the following.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Microdermabrasion
Microneedling
Platelet Rich Plasma (PRP) facial and/or Hair restoration
Red Light therapy/infrared
Reducing melasma (pregnancy mask)
Reducing rosacea
Removing broken capillaries
Removing brown spots/sun damage
Skin tightening
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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