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Zo Peel Consent Form

Skinlogic Med Spa recommends using an at-home regimen of skin health productsto maximize the benefits. This screening will determine who is a good candidate for the ZO 3 step Peel Protocol. YES answers to any of the following questions may disqualify you

Are you pregnant or lactating?

Have you used Accutane® or any prescription retinoid products

(Retin-A®. Renova®) in the last 3 months?

Have you used products containing retinol in the past week?

Are you allergic or sensitive to aspirin?

Are you undergoing any type of radiation or chemotherapy?

Do you have herpes or cold sores?

Within the last week. have you had any facial waxing, electrolysis or used any depilatories?

Do you have any form of auto-immune disease (diabetes. lupus. etc.)?

Do you have a sensitivity or allergy to:

Lactic Acid

Citric Acid

Salicylic Acid

Retinol (Vitamin A)

Latex

Have you had facial cosmetic surgery in the last month (laser resurfacing, dermabrasion. chemical peel. face lift. blepharoplasty, Botox®. in jectible fillers)?

In the past 4 weeks have you been exposed to the sun?

If so, do you have a suntan?

* Note: Some redness is anticipated after the peel.

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.

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May 27, 2020 12:13 am PDT

Zo Peel Consent Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 73.169.190.108