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Skin Brightening Intake & Consent Form

This treatment will help jump start the brightening process by suppressing melanin in the skin and help brighten hyperpigmentation by 1-3 shades. Hyperpigmentation may brighten all over or just in certain areas – results may vary person to person. We highly recommend purchasing the take home BryghtenUp Duo Kit to maintain results.

After your treatment:

Avoid sweating, wiping or getting the treated area wet for a minimum of 2 hours.

Sun Sensitivity: Clients receiving a skin brightening treatment on any areas that will be exposed to sun must use a sunscreen (preferable physical) of at least SPF30 everyday to maintain results.

Ongoing continued use of BryghtenUp products will suppress and prevent future dark spots and skin discolorations, to reveal more radiant looking skin. For best results, use BryghtenUp 2x daily on the area of concern, once in the morning (after working out and/or showering) and once in the evening right before bed for better absorption.

Please note: while most people notice the area is 1-3 shades lighter after the first professional treatment, results vary and you may need several treatments and/or need to use the at-home products over 4-8 weeks to achieve the desired shade.

 

Cancellation Policy: I agree and accept the 24 hour cancellation policy which states that a minimum of 24 hours’ notice must be given to cancel and/or reschedule an appointment. If I fail to do so I agree that I will pay Luna Beauty and Wellness the full amount for the service. If I have a gift certificate/voucher I agree to forfeit its value.

Luna Beauty & Wellness reserves the right to refuse service. Any lewd/disrespectful/sexual/inappropriate comments or behavior will terminate the session and I will be liable for payment of the scheduled treatment. 

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I agree to keep Luna Beauty and Wellness as well as the esthetician updated as to any changes in my medical profile and understand that there shall be no liability on the esthetician’s part should I fail to do so.

Today's date: September 28, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
First Client's Signature*
Second Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Third Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Fourth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Fifth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Sixth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Seventh Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Eighth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Ninth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
Tenth Client's Name

First Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
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.
I confirm that I have read and understand all information on the applicable forms for this treatment or service and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree and give permission for my child to have the above services performed today and going forward as needed. I agree to supervise any home care procedures that are recommended as a result of the treatment. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
Parent or Guardian's Name

First Name*

Last Name*

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

What are your preferred pronouns? *

Referred by: *
Are you currently using/taking:
Accutane
AHA's
Glycolic Acid
Retin-A
Tanning (in the sun or a tanning bed)
Hormone Therapy

List any medications:
Are you currently pregnant or nursing?*
No
Yes
Do you have any allergies?*
No
Yes

If yes, please list:
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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