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Peel Consent

This consent form provides the necessary information to assist patients in making an informed decision regarding receiving the Perfect Derma Peel and/or all our AHA/BHA peel systems.

Our peels are always safe, effective medium depth peel for all skin types & Ethnicities. The products are virtually painless, with no pre-peel skin preparation and little downtime. 

Benefits:

• Improve the overall clarity, tone and texture of the skin

• Reduce or eliminate hyperpigmentation, sun damage and Melasma

• Improve acneic skin conditions and reduce acne scars

• Stimulate the production of collagen, resulting in firmer, more youthful skin

• Reduce the appearance of pore size

Ingredients we use: TCA, Retinoic Acid, Salicylic Acid, Lactic Acid, Mandelic Acid, Glycolic Acid, Kojic Acid, Phenol, Glutathione and Vitamin C

Please note:

The patients skin condition and overall health are considered when determining a chemical peel treatment. Results will vary by individual. An individually designed topical skin care regimen used both before and after the chemical peel treatment is essential to achieve optimal results and shorten recovery time. 

Before receiving a peel, I am responsible for informing my skin care professional about any topical/oral medications or health conditions that may affect this treatment. 

Patients with the following condition(s) will be excluded from receiving a peel treatment:

  • Pregnant or possibility of becoming pregnant
  • Nursing/breastfeeding
  • Warts or active cold sores, Herpes Type I or Type II* (Prophylactic treatment required 1-2 days before treatment in the doses recommended by their prescribing physician)
  • Wounded, Sunburn or excessively sensitive skin
  • History of allergy or sensitivity to any of the ingredients listed above. 
  • Allergy to aspirin, salicylates, Benzoyl peroxide.
  • Vitiligo
  • History of autoimmune diseases including psoriasis, lupus, rheumatoid arthritis, dermatomyositis, multiple sclerosis, or any medical issues that may weaken the immune system 
  • History of any diseases of immune deficiency
  • Inflammatory dermatitis conditions including rosacea, atopic and/or seborrheic dermatitis, systemic lupus erythematosus and dermatomyositis
  • Hyperpigmentation related to the prior use of hydroquinone-containing products. 

I understand if I have a history of cold sores, the peel may cause an outbreak and I am to take an antiviral as prescribed by my primary care physician before and after peel. (Please let your practioner know prior to peel application) 

BEFORE TREATMENT

For forty-eight (48) hours PRIOR to receiving a peel, I confirm I have avoided the following in the desired treatment area(s) 

The use of topical vitamin A derivatives (ie: RETIN-A, Retinoids, Renova)

 

For one (1) week PRIOR to receiving a peel, I confirm I have avoided the following in the desired treatment area(s):

  • Neurotoxin treatments (ie: Botox, Dysport, Xeomin, etc) and am aware that receiving a peel within 2 weeks of neurotoxin treatment may result in neuromodulator migration. 
  • NO skin product prepared in a 100% ethyl alcohol base such as Cleocin topical antibiotic in an alcohol solution
  • Exfoliating products or facial treatments that have been irritating including dermaplaning and microdermabrasion.

 

For one (1) year PRIOR to receiving a peel, I confirm I have avoided the following treatment(s):

  • Accutane (Isotretinoin) use
  • Chemotherapy AND/OR Radiation therapy

 

The chemical peel procedure has been explained to me with all my questions answered and I understand that there will be some degree of discomfort including but not limited to stinging, prickling sensation, heat or tightness during and/or after the treatment. 

I understand that nomedical claims, warranty or guarantees are expressed or implied with this cosmetic treatment. The exact results or benefits of the peel cannot be guaranteed due to many factors.

I understand that why many patients claim peeling starts on Day 3-5, I may or may not see visible peeling and that everyone can and may respond differently to the treatment and that the amount of or absence of peeling does not always relate to the level of improvement achieved. I agree not to pull the skin off any peeling areas or pick any blemishes that may occur within two (2) weeks after the chemical peel as doing so may result in scarring. I will follow the directions and use the products provided in the after care kit.

I understand that although complications are very rare, they do sometimes occur. In this event, prompt treatment or modified instructions for home care may be necessary. If I suspect any complications or have concerns, I will immediately contact my skin care professional or who I am directed to contact the medical team for instructions. 

I understand and agree that direct or extended sun exposure without the use of broad spectrum SPF 30 or and/or use of a tanning bed is NOT advised at any time. Furthermore, during the four (4) weeks following the chemical peel, direct or extended sun exposure and/or use of a tanning bed is not allowed and daily use of broad spectrum SPF is mandatory

I agree to follow skin care professional’s recommended skin care regimen provided to me after the chemical peel treatment to minimize possible side effects and maximize results.

Before receiving my peel, I have been candid and honest in reveling any condition(s) or concern(s) that may have a bearing on this procedure such as those listed above. I authorize Luz Lounge skin care professional to determine which peel would most benefit me and my concerns. I authorize my Luz Lounge skin care professional to apply my peel.

STATE  MEDICAL SERVICES CONTRACT  All Medical treatments are performed by Edmund Fisher MD and Noam Rosines MD Inc. Medical Group, dba Luz 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 enforce ability 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. 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 State 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 agreement upon request.


April 21, 2024

 

 

 


First Patient's Name

First Name*

Last Name*
First Patient's Age Acknowledgment*
First Patient's Date of Birth*
I certify that I am 18 years of age or older
First Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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 Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient'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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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*
Tell us about your skin...
Have you had a chemical peel within the last month?*
No
Yes
Do you experience acne breakouts?*
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?
Do you have any specific skin disorders pertaining to the area to be treated?*
No
Yes

If yes, please specify...
Please confirm you understand and agree to the following statements.
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, I am NOT pregnant or lactating
Yes, I am pregnant and/or lactating.
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. Please select any products that you have a sensitivity to or a known allergic reaction.*
Witch Hazel
Lactic Acid
Resorcinol
None of the above
Salicylic acid
Citric Acid
Retinol
Capryloyl Salicylic Acid
Hexylresorcinol
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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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
Any allergies/sensitivities to aspirin? *
Yes
No
Have you been prescribed Accutane within the last 6 months?*
Do you use sunscreen daily?*
No
Yes
When was the last time the desired treatment area(s) had DIRECT sun exposure/got tanned?*

Please list allergies or sensitivities to medications, ingredients or products. For none leave blank *
History of cold sores?*
No
Yes
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.


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