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Microneedling Informed Consent.

All information is collected by Ivonne Sanchez Beauty pursuant to O. Reg. 136/18: PERSONAL SERVICE SETTINGS and The Personal Information Protection and Electronic Documents Act (“PIPEDA “).

 

Terminology

The words “I”, “you” and “your" are used interchangeably throughout this agreement and in all cases refer to you the client who is receiving the treatment or procedure.

“Practitioner”, “technician”, “instructor” and “we” means 10981508 CANADA INC. (“Ivonne Sanchez Beauty”), its staff or contractors.

Microneedling Informed Consent

I have received a consultation with a member of the Ivonne Sanchez Beauty team and I consent to the treatment of Microneedling or stem-microneedling to be carried out upon myself.

The Microneedling treatment allows for controlled induction of growth factor serums, or hyaluronic acid, into the skin which is understood to be a factor in the self-repair process. Sometimes microneedling is understood to be a form of micro-injury that may stimulate new collagen production, while not posing the risk of permanent scaring. The result is smoother, firmer and younger looking skin. The skin needling treatments are performed in a safe and precise manner with a single use sterile needle cartridge and are usually completed in 60- 90 minutes.

No guarantee can be given to me as to the condition of my skin or degree of improvement expected following my procedure(s). It is recommended that up to 3 to 6 treatments may be needed to obtain desired results or to determine the efficacy of microneedling treatment.

I understand that any skin conditions or concerns must first be discussed with my family physician who is the primary point of contact and owner of my health care plan. Microneedling at Ivonne Sanchez Beauty is not a substitute or alternative to institutional public health care.

I acknowledge that if I am being treated by a physican for any skin diseases or conditions that my doctor must first approve of this microneedling treatment before proceeding.

I understand that multiple treatments may be needed and the use of home care products is recommended to achieve optimal results.

I Agree

I understand that I must follow the provided aftercare instructions given to me by my technician and that I must always wash my hands before touching my skin.

I Agree

If outdoors, I will use protective clothing e.g. hat or sun-brella, and apply broad spectrum sunscreen with SPF-30 or higher, 30 minutes prior to sun exposure and wear daily until all areas treated have healed and after the treated areas have healed.

I Agree

In rare cases, allergies or sensitivities have been reported in products used during treatments (topical numbing).

I understand that the questions in the attached Health Questionnaire may disqualify me as a candidate for any microneedling procedure.

I understand that if I am receiving these services at a discounted rate e.g. as a model in the beauty training program, that the service times and work product will not be the same as a regular service and that I am willing to work with the business or the trainee to support their learning.

I understand that there are no refunds.

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

Microneedling induces physical damage to the skin, which may cause or promote infections if microorganisms are introduced under the skin during the process. The potential sources of microorganisms include:

• Contaminated and/or improperly reprocessed equipment or ink (Ivonne Sanchez Beauty adheres to sanitation protocols and does not reprocess single-use products)
• Client’s own bacteria on the skin.
• Unclean hands touching the treatment area.

Potential infections can be caused by bacteria (e.g., Mycobacterium spp. or Staphylococcus aureus), fungi (e.g., Candida endophthalmitis), or even viruses (e.g., human immunodeficiency virus [HIV], hepatitis B virus, hepatitis C virus)”

Side Effects Typically Include:

  • Skin will be pink or red and may feel warm, like mild sunburn, tight and itchy, which usually subside in 12 to 24 hrs
  • Minor flaking or dryness of the skin, with scab formation in rare cases.
  • Crusting, discomfort, bruising and swelling may occur.
  • Pinpoint bleeding.
  • It is possible to have a cold sore flare if you have a history of outbreaks.
  • Infection is rare but if you see any signs of tender redness or puss notify our office immediately.
  • Hyperpigmentation (darkening of the skin) rarely occurs and usually resolves itself after a month.
  • Permanent scarring (less than 1%) is extremely rare.

In most cases, redness will begin to subside within 24-72 hours.

AVOID EXPOSURE TO DIRECT SUNLIGHT UNTIL THE AREAS HAVE COMPLETELY HEALED. (72 hours)    

I have read and understand the contents of this consent.

Today's Date: July 3, 2020

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age

How you found us:
Area(s) Treated / Treatment Procedure (Please check)
Face
Neck
Decollate
Hands
Other

If other:

Date procedure is scheduled to be performed *

Procedure requested *

Cost *

Health Questionnaire Part 1.

To help avoid unforeseen complications, please answer the following questions.

Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had an aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, please avoid use for 1 month following the procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold)*
No
Yes
Have you ever had any other microneedling treatments prior to this appointment with Ivonne?*
No
Yes

If "yes" when?
Are you taking medication, including immunosuppressives, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic numbing creams, desensitizers, lidocaine or rectal creams.*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
If "Yes" to previous question, have you already consulted a physician to review and treat these conditions or to rule out any disease states?*
No
Yes
Do you have any allergies?*
No
Yes

If "yes" please include details:
Are you currently taking any medication for high or low blood pressure?*
No
Yes
Have you consumed alcohol on the date of the treatment?*
No
Yes

Health Questionnaire Part 2
Please check any conditions, diseases or concerns that you have now or have had
Tuberculosis
Heart issue/pace maker
Trichotillomania
Allergies to makeup
Accutane treatment
Dry eyes
Keloids
Thyroid Issues/Medications
Diabetes (type 1)
Stroke or Paralysis
Chest pains
Shortness of breath
Alopecia
Epilepsy or Seizures
Smoker
Cataract surgery
Tear duct plugs
Planning facial surgery
Cancer
Tan Regularly
Organ transplant
Vitiligo
Laser Treatment (skin)
Scars
Botox
MRSA/Staph
HIV/Aids
Hepatitis
Bleeding Disorder
Kidney Disease
Cold Sores
Glaucoma
Body feels hot
Hyper-pigmentation or Melasma
Autoimmune disorders
Eyelid surgery
Head injury or trauma
Forehead or brow lift
Rosacea
Lash or Brow Growth Serum
I am pregnant or may be pregnant

Please explain any questions marked "YES" or provide any additional details that you feel are important or relevant.

Consent to Be Photographed

I consent to the reproduction and use of my photo(s) without identifying client name or identifying marks with this consent. Consent is for the use of any photograph including but not limited to the use of my photos for any educational purposes, including instruction, display to professional organizations, websites, social media and marketing/advertising thereof.

This consent, as stated above, shall be a continuing consent for all procedures, past, present and future.  Written notice must be received from me the client requesting to discontinue use. (60 days written notice is required).


I give Ivonne Sanchez Beauty permission to use my photo(s) as checked below:
I give Ivonne Sanchez Beauty, its contractors and employees permission to use my photo(s) as checked below:
Full Face
Stomach
All areas of the body excluding nipples, genitalia
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

What date is the procedure being performed?
I understand that all tools that come into contact with my skin are disposable and that either the unique serial, lot or batch number for these items will be recorded against my service notes.*
Yes
No

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus.
I Agree
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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