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?  How many glasses per day?  
Do you drink caffeine?  How many days per week?   
Do you drink alcoholic beverages?  How many days per week?   
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?    
 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 menstral 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

 
 

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.

 

 

* 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 PSTSkin Intake Form & Exfoliation Consent Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 67.183.34.85