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FACIAL CONSULTATION FORM

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FACIAL CONSULTATION FORM


On your next visit ask for a more in-depth personal consultation from our licensed skin therapists. To begin, we need to know a few things about you. 1.) Is this your first introduction to La Ritz skin analysis? Yes or No
3.) Have you ever had a facial treatment before ? Yes or No What type and When?
Yes or No In the last month? Yes or No
a) Always burns easily, never tans b) Always burns, tan slightly c) Burns moderately, tans gradually d) Seldom burns, always tans well e) Rarely burns, deep tan f) Never burns, deeply pigmented
SKIN: ( please choose all that applies ) breakouts/acne , broken capillaries, wrinkles/fine lines, blackheads/whiteheads, redness/rudiness, dull/dry skin, excessive oiliness/shine, sun spots/sun damage, uneven skin tone, dehydrated.
Dehydrated, puffiness, Wrinkles (crows feet), Dark circles 7.) Do you have any OTHER special skin problems or concerns pertaining to your face and body? Yes or No
Specify. In the last 3 months? Yes or No
When and which drug?
Yes or No. Please specify.
11.) Are you taking oral contraceptives? Yes or No specify
15.) What is your current shaving system? wet shave or electric razor .
I understand have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contradictions and or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care institution from liability and assume full responsibility there of.
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Massage Consultation Form

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MASSAGE CONSULTATION FORM 


Please choose: High Blood Pressure, diabetes, asthma, epilepsy/seizures, cuts, bruises, fractures, respiratory disorders, low blood pressure, varicose veins, headaches, spinal disorders, psychological disorders, arthritis location, pregnancy, heart diseases, phlebitis, Fibromyalgia, surguries, Gastrointestinal Problem, Muskuloskeletal Disorders, stroke, cancer, gout, stress, TMJ Disfunction, accidents, skin disorders..Please explain any chosen illness.
Herbs ( ) Yes () No if yes, list
Yes or No
I understand that the massage/bodywork I receive is provided for the basic purposes of relaxation and relief of muscular tension. There are certain medical conditions in which receiving a massage may not be appropriate. In those cases a referral from a physician may be required prior to services being provided. Massage/bodywork is not a substitute for medical specialist. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure/strokes may be adjusted. In addition, if I am uncomfortable for any reason. I may ask that the session be stopped immediately. Draping will always be used during sessions. No breast massage will be done without the written consent of the client and the therapist. Any illicit or sexually suggestive remarks or advances made by me ( the client ) or the therapist will result in an immediate termination of the session.
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ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM

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ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM


Any form of blood sickness, Skin diseases or sickness, Heart disease, Metal inside the body, pregnant, Tumors.
I understand,have read,and completed this document truthfully. Iagree that this constitutes full disclosure,and that it supercedes any previous verbal or written disclosures.I understand that withholding information or providing inaccurate information is serious.The treatments I receive here are voluntary and I release my body institution from liability and assume full responsibility thereof.
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WAXING CONSULTATION FORM

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WAXING CONSULTATION FORM


Please choose whether you have now or ever had any of the following medical conditions: Diabetes, dermal abrasions, stomach ulcers, high blood pressure, excessive moles, poor circulations, warts, varicose veins, any other skin conditions (please explain below)
Acadian, tetracycline, coition, high blood pressure, thyroid med, rein-A, glycolic acid, alpha hydroxy acid, any other medications (please explain below)
Tanning (sun), Tanning (bed), Chemical peel, Waxing
Do not expose skin to sun/indoor tanning for at least 48 hours after the waxing service.I understand that i am accepting any reactions from a waxing service.
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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

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FOOT DETOX CONSULTATION FORM


**If you answered "yes" to 4 or more of the above questions or answered "no" to questions 22, then you are a good candidate for foot detox and would greatly benefit from a # month detoxification treatment schedule**
Use a pacemaker or other electronic medical equipment, take medication for hypertension, have had an organ transplant, take specific medicine for a psychological condition, are you pregnant or nursing, persons with Epilepsy, persons with open wounds in their feet, person currently undergoing any form of radiation or chemotherapy, people who are hemophiliac and those taking blood thinners, children under 8 yrs old.
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