Loading...

 

Lüz Lounge
1229 Montana Ave STE A

Santa Monica, CA. 90403

310-401-9001

4801 Woodway Dr STE 465E

Houston, TX 77056

Informed consent for SkinRx + All Facial/Skin Care Treatments

 

This consent form provides the necessary information to assist patients in making an informed decision regarding receiving Skin Care Treatments that include, but are not limited to, Facials, extractions, microdermabrasion, chemical peels and the use of topical skin care products.

Microdermabrasion is a mechanical method of removing the outermost layers of the skin through the use of abrasive elements such as a diamond-tipped pad. 

Chemical peels remove the top layers of the skin through the use of light to mild strength acids.

ClearLift™ is a non-ablative approach to laser skin resurfacing. ClearLift providers are able to offer patients skin resurfacing treatments that are fast and virtually painless with visible results* and no downtime. The innovative technology delivers a controlled dermal wound deep beneath the skin, (up to 3mm in depth). The outer layer of the skin is left undamaged. All stages of healing and skin repair occur under the intact epidermis.

Alternative treatments to microdermabrasion and chemical peels include laser skin resurfacing, dermabrasion, plastic surgery, or no treatment at all.

Our medical 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 resulting in firmer,  smoother  and  younger  looking  skin.   These  procedures  are  normally  performed  within  30-60  minutes  depending  on  the  size and  area  being  treated.   

Please Note:  The use of topical vitamin A derivatives (RETIN-A, Retinoids) is contraindicated and must be discontinued 2 weeks before and 2 weeks after treatment.
If you have been prescribed or have taken Accutane within the last 6 months, you may not be able to receive any laser related treatments. Both Accutane and Vitamin A derivatives are direct contraindications and can lead to severe damage. It is recommended that you wait 2 weeks before and after your treatment for any waxing procedures to be completed.

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

  • Prolonged erythema (redness) or edema (swelling)
  • Allergic reactions
  • Blistering
  • 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. I have disclosed any condition that may have bearing on this procedure such as: pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as antibiotics, accutane and/or retinoids.

I understand that the following possible side effect and/or risk could occur:  

Most people heal without any problems. However, here are some problems that you may encounter: If you are prone to getting fever blisters (herpes simplex) then you might even 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. 

 

You might notice small white dots appearing on the skin. These might be simple little retention cysts (Milia) or they could be minute infected areas. Carefully but firmly wipe them away and apply an antibiotic lotion. It is a good idea to consult your doctor about this. Do not allow the white dots to remain on the skin and if you are not able to remove them yourself then please consult with your doctor.  

 [initial]

If the skin becomes painful and redder, then you may have developed an infection and you must see your doctor at once.  

 [initial]

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.

April 21, 2024

 

STATE MEDICAL SERVICES CONTRACT  

All Medical treatments are performed by Edmund Fisher MD (Santa Monica) or Noam Rosines (Houston)  Inc. dba Lüz Lounge

A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement CD0501Y8v2

ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by State law, and not by a lawsuit or resort to court process except as State law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages.  Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph.  Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of State. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place.. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court. Discovery shall proceed in accordance with Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division.  Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions.  NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP  YOUR RIGHT TO JURY OR COURT TRIAL. 

I have read and agree to the terms/conditions listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request.

 April 21, 2024

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
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
Not applicable
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
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.
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
Female clients, do you have a regular menstrual cycle?*
No
Yes
Not Applicable
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*
Parent or Guardian's Date of Birth*
Parent or Guardian's 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 in the last 7 days anywhere on your face, back, neck or chest?
Face
Neck
Back
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 learning more about.... Select all that apply
Acne laser facials
Botox
Chemical peels
Clearlift laser facials
Coolsculpting (fat reduction and body contouring)
Cortisone injections for cystic acne
Dermal fillers
Developing a customized 3, 6 or 12 month skin care plan
Eyelash extensions
Facials
General skin care consult
Improving uneven skin texture
Intense Pulsed Light facials (IPL)
Laser hair removal
Micro-blading eyebrows
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
Tattoo removal
Teeth whitening
Ultherapy or High Intensity Focused Ultrasound (HIFU)
Vitamin B-12 injections
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!