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Client consultation and release form. Please read carefully.

Client Consent Form

1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months


2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day or two days before, same day and two days after any aggressive facial exfolation treatment.


3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Appearance of pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen


 

4. I acknowledge that my skin might experience temporary irritation, tightness, or redness which usuall dissipates within 72 hours depending on skin sensativity


5. I acknowledged that if I am allergic to one or more of the ingrediants in the products used, I may experience allergic reactions


 

6. I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to suburn, sun damage and hyperpigmentation. I should avoid excessive sun exposure, especially between 10am-2pm.


7. I acknowldge that this treatment is strictly an eelctive cosmetic procedure and that no medical claims have been expressed or implied


8. I acknowledge that I should avoid use of aggressive exfoliation, waxing, and products containing acids that are not part of recommended take-home regimen for 2-4 weeks following the treatments


9. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my physician or skin care practioner during the following treatment


10. I acknowledge that I am not pregnant or lactating


11. I hereby agree to have the treatment performed and agree to follow all pre and post treamtent instructions


12. I acknowledge that I have answered all questions truthfully


13. I release Edge Systems, Lisa Primps, management and staff of The Primping Place from any and all liability associated with any injuries and/or current or future coniditions resulting from the skincare procdures or products


All transactions are final, and The Primping Place does not offer any money-back guarantees. You recognize and agree that you shall not be entitled to a refund for any service, under any circumstances.

By signing below, I certify that I have read and fully understood the contents of this consent form, and that the information I provided above are complete, accurate and up to date to my knowledge.



 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you have any of the following allergies? *
Aspirin
Preservatives
Shellfish
Sulfur
N/A
Accutane or other similar medication*
No
Yes
Autoimmune disease, HIV, lupus, hepatitis, scleroderma*
No
Yes
Blood thinners - Heparin, Coumadin, Warfarin, Daily Aspirin/NSAID or Vitamin E, etc.*
No
Yes
Cancer or post cancer treatments*
No
Yes
Cardiovascular issues*
No
Yes
Cold sores or fever blisters without pre-medication*
No
Yes
Cortisone or steroid injections*
No
Yes
Cosmetic injections, fillers or implants*
No
Yes
Eczema, psoriasis*
No
Yes
Enlarged or painful glands*
No
Yes
Epilepsy*
No
Yes
Facial waxing services within 7-14 days*
No
Yes
Heart ailment*
No
Yes
Hypertension/high blood pressure*
No
Yes
Inflammatory conditions*
No
Yes
Irregular, pigmented moles, warts or growths, unidentified facial growth or mark*
No
Yes
Keloids, pigmented scars, icepick scars, new scar tissue*
No
Yes
Laser procedures, chemical peels, dermabrasion, microdermabrasion*
No
Yes
Light sensitive medication*
No
Yes
Loose, thin, aged skin*
No
Yes
Lymphatic disorder, inflammation of lymph vessels, lymphedema*
No
Yes
Are you on medications?*
No
Yes

If yes, please list them
Phlebitis, varicose veins*
No
Yes
Recent accident or serious injury*
No
Yes
Recent surgical or dental procedure*
No
Yes
Rosacea, telangiectasia/couperose*
No
Yes
Retin-A or Retinol*
No
Yes
Skin abrasions or lesions*
No
Yes
Stage III or Stage IV acne*
No
Yes
Skin-lightening or bleaching agent*
No
Yes
Sunburn*
No
Yes
Swollen or infected tonsils*
No
Yes
Thyroid conditions*
No
Yes
Type I diabetic*
No
Yes
Under medical care for an existing or suspected condition or disease*
No
Yes
Viral infection, influenza*
No
Yes

If you answered yes to the medications or any questions after please explain why

What is your interest in skincare procedure primarily for *

Specify your areas of concern *
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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