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Skin Care Information and Release

I understand that:

  • The goal of a facial is to hydrate and deep cleanse facial skin, to massage and stimulate the blood and lymph circulation, that improves the skin tones and texture, acne breakouts and general skin health.
  • Every person is unique and skin condition and results may vary, so it is very difficult to guarantee a specific number of treatments needed. Results vary with the individual and in the case of acne and sun damage depend on the amount of acne and compliance with recommended adjunctive measures and skincare.
  • These Facial treatments are recommended every one to two months depending on the skin type and condition for optimal results.
  • Certain facial treatments may be performed any time before special events.
  • Common side effects such as slight redness usually subside within a few hours after treatment.
  • Rare/Uncommon side effects such as bruising, skin irritation, lightening or darkening, allergic reactions and exacerbation of skin breakout can occur. 

What to expect:

  • After my Facial Treatment, my skin may experience temporary irritation, redness, or tightness. These reactions are all normal, and may typically resolve within 48-72 hours depending on skin sensitivity.
  • The following sensations may be experienced within a few hours after Ultra Lift Facial: tingling and stinging in the treatment area.
  • Client experiences always vary. Some patients may experience a delayed onset of these symptoms.
  • Majority of Facial customers see the results immediately after treatment and their skin may feel smooth and hydrated for few weeks with appropriate home care to maintain treatment results.
  • After a Facial Treatment the skin needed to be protected of sunburn/sun damage. All patients should avoid excessive sun exposure and use a minimum of SPF 40 sunscreen. 


Client
By signing below, I acknowledge that I have sought out this treatment and accept the terms. 

Signature:

Date: May 7, 2024

First Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
First Client's Signature*
Second Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Third Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Fourth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Fifth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Sixth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Seventh Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Eighth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Ninth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Tenth Client's Name

First Name*

Middle Name

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

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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(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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Home phone

Mobile phone

Occupation

Hours per week

Referred by
Do you have any health problems or concerns or conditions that I need to know about before we begin this treatment?*
No
Yes
Do you have allergies to any plants, oils, lotions or ingredients?*
No
Yes
Are you pregnant?*
No
Yes
Any recent surgery on your face, neck or shoulders?*
No
Yes
Do you smoke?*
No
Yes
Have you taken Accutane® or other prescription medication including creams, lotions, and ointments in the past 12 months?*
No
Yes
Have you used Retin-A®/Renova®, or any powerful alpha hydroxy products in the past 3 months?*
No
Yes
Have you had a medical peel within the last six months?*
No
Yes
Do you have a Pacemaker ,Pins in bones, amalgum/murcury fillings or any metal in your body?*
No
Yes
Do you currently wear contact lenses?*
No
Yes
Are you currently under a physicians care for any skin condition?*
No
Yes
Have you ever had an adverse reaction to a cosmetic product or ingredient?*
No
Yes

What are your skin concerns or challenges?

What are you currently using on your skin?

My esthetician my choose to do surface exfoliation on my skin and will discuss this with me before beginning. If she does, I give my concent.
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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