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Advanced Skin Care / Aesthetics / Bodywork

Please answer the following questions honestly to ensure your comfort and safety. The information provided will be held in complete confidence.

I understand that response to treatment varies on an individual basis and that specific results are not guaranteed.


I understand that there are no refunds provided for any reason whatsoever.



Please select who will be participating...
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First Client's Name
First Name*
Middle Name
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
Information
Date of first visit *
First Client's Signature*
Client's 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
First Name*
Last Name*
Emergency Contact's Phone Number*
How did you find Dermaspalogy by My Derma Clinic?*
What is your greatest beauty concern?*
Are you or might you be pregnant?*
No
Yes
Are you lactating?*
No
Yes
Are you presently in good health?*
No
Yes
Do you feel well today?*
No
Yes
Date of your last medical exam?

Are you currently under a doctor's care? If you answered yes, please explain.
Please list any allergies including essential oils, herbs, fragrances, skin care products/ingredients, foods, iodine, shellfish, medications, etc. *
Are you now or have you previously taken any Retinol-based or any other Vitamin A-based products/medications such as Accutane or Retin-A (if yes, please list)? *
Are you now or have you previously taken any other acne medication? If yes, please list the medication and when/for how long you took it. *
Do you take any anti-coagulant (blood thinning) medication? If yes, please list. *
Have you been on antibiotics within the past 2 weeks?*
No
Yes
Are you taking St. John's Wort?*
No
Yes

Please list any other medications you are currently taking and why you are taking them (include hormones, birth control, vitamins, herbs, antibiotics, etc). *
Do you suffer from oral herpes, fever blisters or cold sores? If yes, how often and what medication do you take? *
Are you sensitive to heat or cold?*
No
Yes
Do you smoke?*
No
Yes
Do you have any open sores, rashes or other skin condition in the area to be treated?*
No
Yes
Do you now or have you had migraines triggered by lights or similar light-sensitive disorders?*
No
Yes
Do you have any metal implants (except fillings), a pacemaker or a copper IUD?*
No
Yes
Are you claustrophobic?*
No
Yes
Are you prone to epileptic seizures?*
No
Yes
Do you think you might have / do you have / have you had / and/or are you being treated for:
Current or past history of any disorder, surgery or issue involving the gall bladder or liver?*
No
Yes
Chronic back problems?*
No
Yes
Any vertebral problems (e.g. scoliosis, kyphosis, spina bifida, a herniated or bulging disc?*
No
Yes
Thrombosis/blood clots?*
No
Yes
Varicose/spider veins?*
No
Yes
Hormonal problems?*
No
Yes
Menopause?*
No
Yes
Thyroid (over/under)?*
No
Yes
Heart problems?*
No
Yes
Vascular disease?*
No
Yes
Diabetes?*
No
Yes
Cystic acne?*
No
Yes
Acne light, heavy, other?*
No
Yes
Hypoglycemia?*
No
Yes
Hysterectomy?*
No
Yes
Eczema?*
No
Yes
Seborrhea (oily scalp)?*
No
Yes
Narcotic drug use?*
No
Yes
Alcoholism?*
No
Yes
Hepatitis?*
No
Yes
Cancer of any kind?*
No
Yes
Heavy menstrual cycle?*
No
Yes
Hirsutism (excessive hair)?*
No
Yes
Sinus problems?*
No
Yes
Immune system disorder?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had any surgical procedures in the area to be treated?*
No
Yes
Have you had any dermal fillers or implants in the area to be treated?*
No
Yes

If you answered yes to any question above, please explain. *

Is there anything else about your health and/or skin that we should know? *
Skin Type
Do you tan easily?*
No
Yes
Do you burn easily?*
No
Yes
What color are your eyes? *
Acknowledgement

I acknowledge that beauty and medispa treatments, including, but not limited to: skin care, massage, microblation, microdermabrasion, waxing, hair and scalp treatments, nail treatments, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, other neurotoxins, Kybella, Collagen, Dermal Fillers, PRP injections, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference. 

On behalf of myself, my heirs, my executors, and my administrators, I understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, skin damage, nerve damage, disability, death, scarring, infection, change in skin pigmentation, allergic reaction, eye damage, change or damage to my vision, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, indemnify, hold harmless and release from any and all liability, costs of litigation and any other costs of every kind and nature, the company and the individual that provided my treatment, the insured, their insurance company, and any additional insureds, as well as any officers, directors, or employees of the above companies for any injury, property damage, condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.

The release contained herein will be construed to apply to the greatest extent permitted by law and, if permitted by law, will apply even if such injury or damage is caused in whole or in part by the released parties’ own negligence or the negligence or willful conduct of any other individual. 

In the event any provision of this agreement is found to be legally invalid or unenforceable for any reason, all remaining provisions will remain in full force and effect. In the even any provision of this document is found by a court of competent jurisdiction to exceed the limits permitted by any applicable law or to be invalid or unenforceable as written, such court(s) may exercise its discretion in reforming such provision(s) to the extent necessary to make it reasonable and enforceable.

I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties. It is understood that any such arbitration will be final and binding and that by agreeing to arbitration, the undersigned is waiving their rights to seek remedies in court, including the right to a jury trial. The undersigned waives, to the fullest extent permitted by law, any right they may have to a trial by jury in any legal proceeding directly or indirectly arising out of or relating to this agreement whether based in contract, tort, statute (including any federal or state statute, law, ordinance or regulation), or any other legal theory.

The insured agrees that this contract will be governed and construed in accordance with the laws of the state of South Dakota and that all actions of any kind whatsoever will be heard, governed, arbitrated, and restricted to the venue of the County of Meade County, South Dakota. The undersigned also agrees and stipulates that they will be responsible for any legal, or other costs of any kind, incurred by the insured or their insurance company in defense of this agreement should the undersigned challenge its enforceability.

The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature the insured, and their insurance company for the transmission of any disease, condition, injury or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured’s location or the location of treatment. 

I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. In consideration for treatment received, I hereby grant permission to the individual or company that provided my treatment to use any photographic treatment records for the purposes of clinical and statistical studies, advertising, or promotion without any additional compensation to me.


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*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Date of first visit *
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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