Skin Intake Form & Exfoliation Consent Form


Please Fill out all boxes below as there are two sections both the Skin Intake Form & Exfoliation Consent Form. 

    
 

 

Emergency Contact    

What is your current gender identity?

What pronouns do you prefer that we use when talking about you?

What are the primary concerns about your skin?   
What goals do you have for your skin?  

Do you drink water daily?  
Do you drink caffeine?  
Do you drink alcoholic beverages?   
Do you smoke?   
Do you exercise regularly?  
Do you have regular sleep? patterns?  
Do you work outside?   
Do you use daily UV protection?   
Have you ever taken Accutane?   
Do you have any drug allergies?   
Have you ever had cancer? 
Do you have herpes?   
Do you have any auto immune diseases?   
Are you claustrophobic?   
Have you ever had a massage?  If yes you like your touch to be

What brands are you currently using on your skin?

 



   


Female clients for this section Only
Are your menstrual cycles regular?
Do you take birth control pills?
Are you menopausal?  If yes what stage?
 

Are you pregnant or trying to get pregnant?  
Are you breastfeeding?

Environmental Allergies   
Allergies to Medications 
Allergy to Latex

Please list any health concerns you have had or are now experiencing.  
Please list any oral and over-the-counter you are taking. Include vitamins and herbs.  

Is there anything you would like our treatment providers to know before your treatment? 

INFORMED CONSENT AND RELEASE

FOR THE USE OF PEELING AGENTS AND MODALITIES

This is an information and consent form for treatments performed at Skinlogic Med Spa which include peeling agents, microdermabrasion and hydroxy acids.

The peeling of the skin to regenerate new tissue is accomplished with a chemical solution or microdermabrasion to achieve the best results. During your treatment, you may experience some stinging, warmth, and /or a flushing feeling in the skin; this feeling generally fades in 5 minutes. The next few hours after your treatment, you may feel tightness in the skin, and over the next several days to 2 weeks, the treated areas may appear pink or red and progressively become darker, this depends on variances of application.

For a lighter peel, you may only experience light flaking or nothing at all. For scar treatments and deeper exfoliation, you may experience a thick peeling/crusting and redness/tenderness a couple of days after, this may last for up to a week. For most people if there is peeling, it will begin to occur within 48 hours. It is impossible to know how much peeling will occur for each person.

These reactions are normal and usually desirable to achieve the desired result.

The possible risks and downfalls of these treatments are uncomfortable dryness/tightness, unattractive swelling, and peeling of the skin, pinkness or redness along with bruising and skin darkening to brown during the peeling stages. Hyper‐pigmentation can occur in some individuals. Allergic skin reactions are rare but can also occur.

Please follow these instructions for best results

  1. No Sunning or Tanning during these treatments, this can lead to undesirable burning and cause damage to skin.
  2. Home care instructed by your Skinlogic Skin Therapist should be followed for best results.
  3. Report any conditions you have regarding eczema, cold sores or herpes anywhere on the face.
  4. Do not receive this peel if you have unrealistic expectations.
  5. Advise Skinlogic regarding any outdoor activities you have planned this week.
  6. A minimum daily application of SPF should be applied.
  7. Discontinue Accutane for 6 months prior to any repair treatments

I have read and agree to adhere to the recommendations that have been presented to me and that will be discussedduring my pre peel consultation. I hereby give my consent for a Skinlogic Skin Therapist to perform a skin peel on myself. I also authorize and release Skinlogic from any claims, implied or stated that I have or may have in the future in connection with this treatment, regardless of result. I am aware of the risks mentioned above and information on the treatment I am receiving has been explained to my satisfaction.

 

Cancellation Policy:

Your allocated appointment times are reserved especially for you and are very important to us. We have implemented this cancellation policy because we value the business of our clients and the time of our staff. All of our policies are designed to benefit our current clients and our future clientele. Therefore, we respectfully request at least 24 hours’ notice for adjustments to your appointments and for cancellations.  Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need.

I understand that as a new or current client of Skinlogic Med Spa that I supply a credit card to have on our files. All cards on file are added to the system via a secure electronic process that ensures the information is encrypted and remains secure. In the event that we do not receive the required 24 hour notice for adjustments and cancellations a $50 fee will be applied to your card.

I have read the above Cancellation Policy and agree to its terms and conditions.  I hereby give my consent for  Skinlogic Med Spa to securely store my credit card on file and authorize Skinlogic Med Spa to charge my card if I cancel less than 24 hours before any future scheduled appointments.

 

* Please turn off your cell phone as a courtesy to others. I have read and completed the above thoroughly and to the best of my knowledge.

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Document name: Skin Intake Form & Exfoliation Consent Form
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May 17, 2020 10:05 pm PDTSkin Intake Form & Exfoliation Consent Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 73.169.190.108
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