CLIENT CONSULTATION FORM FOR FACIAL

This is a combined consent form for Microdermabrasion, Dermaplaning, Chemical Peel, Waxing and Electric Modalities. We ask to sign this form every 12 months. Please put a check mark next to the service you are scheduled to receive and any additional services for future consideration to ensure no further paperwork will be needed until its 1 year expiration.

My esthetician has provided information and answered any questions I have regarding my treatment: expectations, contraindications, allergies, side-effects (bruises, scabbing, scarring, redness, swelling, tenderness, hyperpigmentation, break outs, flare up, dryness/dehydration, peeling, itchiness, irritation, edema, erythema, stinging, burning, nicking, cutting), pre and post care, and precautions. In the event that I may have additional questions or concerns regarding my treatment or suggested home products, post treatment care, I will consult with my esthetician immediately.

Description of Services and Contraindications

Please check the service you have scheduled for or would like to schedule in the near future.

*Contraindications for Microdermabrasion, Dermaplaning, Chemical Peel and Waxing:

• Ingredient allergies
• Active facial rashes
• Open or unidentified lesions (Herpes Simplex/Cold Sores)
• Any type of dermantitis, including eczema, psoriasis and seborrhea
• Sun exposure (2 weeks before and after scheduled treatment)
• Weakened immune system
• Serious illness
• Pregnancy or lactating (applied for Chemical Peels)
• Accutane usage (must be off accutane for 1 year to receive any of the above services)
• Diabetes
• High Blood Pressure (if you have this condition, please check with your Physician prior to receiving the desired service if it is safe for you to do so)
• Heart Disease (if you have this condition, please check with your Physician prior to receiving the desired service if it is safe for you to do so)
• Waxing (have to wait 3-5 days after waxing to receive microdermabrasion, chemical peel or dermaplaning)
• Botox (you have to wait 1 week before and after to receive any services mentioned above)
• Injectables (you have to wait 2 weeks before and after to receive any services mentioned above)
• Microblading (you have to wait 2 weeks before and after to receive any services mentioned above)
• Permanent Makeup (you have to wait 3-4 weeks before and after to receive any services mentioned above)
• IPL (you have to wait 2-4 weeks before and after to receive any services mentioned above)
• Laser Resurfacing (you have to wait 3-6 months before and after to receive any services mentioned above)
• Cosmetic Facial Surgery (you have to wait 3-6 months before and after to receive any services mentioned above)

*Contraindications for Microdermabrasion, Dermaplaning, Chemical Peel and Waxing:

• Epilepsy or subject to seizures
• Recent surgery
• Pacemaker or electrical implanted device
• Active cancer
• Pregnancy
• Under the age of 18