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FACIAL CONSULTATION FORM
FACIAL CONSULTATION FORM
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FACIAL CONSULTATION FORM
FACIAL CONSULTATION FORM
Massage Consultation Form
Massage Consultation Form
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MASSAGE CONSULTATION FORM
MASSAGE CONSULTATION FORM
ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM
ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM
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ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM
ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM
WAXING CONSULTATION FORM
WAXING CONSULTATION FORM
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WAXING CONSULTATION FORM
WAXING CONSULTATION FORM
CHEMICAL PEEL/MICRODERMABRASION CONSULTATION FORM
CHEMICAL PEEL/MICRODERMABRASION CONSULTATION FORM
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CHEMICAL PEEL/MICRODERMABRASION CONSULTATION FORM
A Skin peel is not a "cure-all" treatment,but for appropriate conditions,it can improve the skin. It is very important that you have a thorough understanding of what a peel can and cannot do for your particular condition. Please initial each statement and sign this form
I,________________________________________________________________give microdermabrasion consent to ___________________________________________
to perform a skin peel/microdermbrasion treatment on my face or body in order to treat the following conditions:__________________________
_____________________________________________________________________________
_______ The peel treatment was explained to me.
_______I understand that the degree of improvement I can expect to see is dependent on many variables,and therefore cannot be guaranteed.
Additionally, I understand that good home care and adherence of ALL
instructions is vial to ensure my best results.
______I understand that this program of treatment, and that I may need several peels in order to achieve my best results.
______ I understand that I can expect to have 1-2 minutes if stinging or burning immediately after the peel has been applied- or no longer with certain peels.
______ I have ceased the use of Hydroquinone/Salicylic/Glycolic acid products, 1 week prior to service.
______ I have not received any chemical hair treatments (permanent wave,straightening,relaxers,coloring, or bleaching) 1 week prior to service.
______ I do not at this time suffer from HIV, Hepatitis,Herpes, simplex
( cold sore ) infections or facial warts. (Note: the appearance of a cold sore on the lips or any other portion of the peeled area must be cared for immediately.The cold sore can spread if not treated promptly.)
______I have informed the esthetician if I suffer from diabetes.
_____I am not currently undergoing chemotherapy,radiation, treatments or using anti-cancer drugs at this time.
_____ I am not pregnant or breastfeeding at this time.
_____I am not sun burned at this time.
_____I do not have permanent make-up ( eyeliner,brow liner,lip-liner)or I have notified the esthetician so that my tattoo will be covered as not to fade or discolor ink.
_____I understand that I MUST use an SPF of at least 30 for the next 2 weeks following each treatment. (Physical sunblock is recommended,
A quratre size amount must be applied every morning.) I will avoid direct sun as much as possible and wear a hat when I am outside.
______ I understand that the use of tanning beds in between treatments will nuliffy the results achieved and worse, can cause sever burns.
______ I have not been taking Accutane for the past year.
______I have not notified the esthetician of any allergies to ASPIRIN or SHELLFISH.
PATIENT CONSENT:
The esthetician has explained to me the possible complications of the proposed chemical peel and I have sufficient opportunity to ask questions.I understand that the chemical peel treatments cause a burning sensation that will last several minutes. Multiple peels may be necessary to achieve the desired results,especially with light chemical peels,depending on my skin type and the nature of my skin problem. I have realistic expectations as to degree of improvement a chemical peel may provide.
After receiving and understanding in full the information above, I freely give my consent to undergo the chemical.I understand that this procedure is cosmetic and that the payment is my responsibility. My questions have been answered by the staff to my satisfaction.I release
the esthetician of liability and I accept the risks and complications of procedure.
_____________________________
Patient/Client Signature
______________________________
Witness Signature
_____________________________
Date
By signing below,I am standing that there are no changesfrom when I signed this consent.I have not started any new medications or been in the tanning beds,etc. I consent to the chemical procedure and agree to all the information that i has signed previously.
Treatment 1
___________________________________________________________________
Signature/Date
___________________________________________________________________
Witness/Date
FOOT DETOX CONSULATATION FORM
FOOT DETOX CONSULATATION FORM
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FOOT DETOX CONSULTATION FORM
FOOT DETOX CONSULTATION FORM
Microblading consultation form
Microblading consultation form
V-STEAM CONSULTATION FORM
V-STEAM CONSULTATION FORM
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We love hearing from you, let us know what's on your mind