Skin Treatments Form

Skin Treatments Form

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Birthdate:*
ex. 01/05/1960
Phone:*
ex. 555-555-5555
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you to skinSPArations?*
What do you consider your skin type?*

NormalOilyAcneDryAgingCombinationSensitiveRosaceaOther
What is your daily skin care regimen?*
Are you allergic to anything?*

NOYES
If yes, please list allergies:*
Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?*

NOYES
If yes, please list reason:*
Have you had skin cancer?*

NOYES
If yes, please list area(s):*
Do you have any permanent cosmetics or tattoos on the areas being treated?*

NOYES
Have you had any of these health conditions in the past or present? *

CancerHormone imbalanceSystemic diseaseHigh blood pressureThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsyFever blistersHepatitisHerpesCold soresImmune disordersHIV/AIDSLupusMetal implantsPhlebitisBlood clotsInsomniaSeizure disorderKeloid scarringMigranesSkin diseaseActive InfectionNONE, I am in good health
After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 24 hours.

Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.
Do you smoke or chew tobacco products everyday?*

NOYES
List any oral MEDICATIONS you take daily:*
List all oral VITAMINS or HERBS you take daily:*
Do you currently use any of the following?*

Retin-ARenovaAdapaleneDifferinGlycolic AcidSalicylic AcidBenzoyl PeroxideHydroquinoneHydrocortisoneAHA/BHARetinolAccutaneTazoracRoAccutaneScrubs or PeelsNONE
I understand that I must discontinue use of ALL of the above 5 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.*

YES, I will discontinue.
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?*

NOYES
If yes, please explain:*
Do you use bleaching creams or Hydroquinone daily?*

NOYES
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

NOHyper-pigmentHypo-pigment
Have you used an acne medication? *

NOYES
If yes, please list medication:*
Have you had a reaction after having a facial treatment in the past?*

NOYES
Please explain the details:*
Have you ever had an ALLERGIC reaction to any of the following?*

AHA'sRetinoidCosmetics"Sea" ProductsCitrus ProductsMedicineFoodAnimals / InsectsSunscreensIodinePollenFragranceShellfishLatexTopical RXNONE
Female Clients
Are you pregnant or trying to become pregnant?*

NOYES
Do you have Mirena IUD, Copper IUD or other implanted birth control?*

NOYES
Are you taking oral birth control?*

NOYES
Are you lactating or breastfeeding?*

NOYES
Any current menopause problems?*

NOYES
If yes, please explain:*
Skin Care History
Do you like scented or unscented products?*

ScentedUnscentedNo preference
Do you wear foundation?*

NOYES
How often do you use a skin regimen?*

1x per day2x per dayI do not use a regimen
Do you feel claustrophobic during facials?*

YESNO
Do you have an aversion to hot or cold tempuratures used on your face?*

YESNO
What conditions would you like to improve?*

AcneOily SkinDry SkinBumps/TextureLarge PoresMelasmaRednessBrown SpotsSun DamageMiliaSagging SkinRosaceaLines & WrinklesHealthy AgingWhite spotsScarringAge ManagementKeratosis PilarisHyperpigmentationHypopigmentationSkin ToneSkin TagsOther
List any additional conditions you would like treated:*
Dermaplaning & Peels

I understand and accept the following statements:
- this procedure uses a Dermaplaning blade, which is mildly abrasive therefore I will follow the explicit instructions of my skincare therapist. Additionally, nicks to the skin can occur due to the sharp surgical blade. Patient will be notified and the area will be treated if necessary.
- Enzyme/Chemical Peels are part of this treatment I understand that the sensation and penetration of the peel will be enhanced. Which may cause skin irritation, mild discomfort, and tenderness, lightening or darkening of the skin, infection, scarring, peeling, and activation of cold sores.
- If I am prone to herpetic outbreaks, I understand that I may be advised to see a physician about appropriate prescriptions or supplements to control outbreaks prior to treatments.
- There are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc.
- Tthis treatment is a cosmetic treatment and that no medical claims are expressed or implied.
- To achieve maximum results, I may need several treatments and follow my prescribed home care regimen.
- I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment and during the 10-14 days, prior to and following the end of treatment (we recommend that this practice be discontinued altogether).
- I have not had any other chemical peel of any kind within 10-14 days of this treatment.
- I understand I cannot have another chemical peel within 10-14 days of this treatment, whether it is performed at this location or any other location.
- I will call to inform my skincare specialists of any complications or concerns as soon as they occur.
I have read and accept the above Dermaplaning & Peels statements*

I agree, accept and understand the about statements
MicroNeedling

I understand and accept the following statements:
- My practitioner will apply a topical anesthetic to your skin prior to treatment to reduce any pain and discomfort.
- My skin will be pink or red in appearance, much like a sunburn, for a couple of hours following treatment.
- Minor bleeding and bruising is possible depending on the length of the needle used and the number of times it is pressed across the treatment area.
Possible Side-Effects:
- Side effects or risks are minimal with this type of treatment and typically include minor flaking or dryness of the skin with scab formation in rare cases.
- Milia (small white bumps) may form; these can be removed by the practitioner.
- Hyper-pigmentation (darkening of certain areas of the skin) can occur very rarely and usually resolves after a month.
- If you have a history of cold sores, this procedure may cause flare ups.
- Temporary redness and mild-wind burn effects may last up to 4 days.
- Freckles may temporarily lighten or permanently disappear in treated areas.
- Other potential risks include: crusting, itching, discomfort, bruising, infection, swelling, and failure to achieve the desired result. Permanent scarring (less than 1%) is extremely rare.
I have read and accept the above MicroNeedling Statements*

I agree, accept and understand the about statements
Body Treatments

I understand and accept the following statements:
- I understand that the enzyme body scrub that I receive is provided for the basic purpose of relaxation and exfoliation of dead skin cells. I understand that the exfoliation of dead skin cells is an abrasive procedure; if I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure may be adjusted to my level of comfort.
- I understand that my practitioner does not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with that treatment of a licensed medical professional. I understand that a body scrub does not take the place of medical care. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have.
- I understand that for my privacy, towel(s), wrap, and dispoable covers will be provided to cover the breast and pelvic areas.
- I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
- I affirm that I have stated all of my known medical conditions, medications, and answered all questions accurately and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so
Possible Side-Effects:
- Boosts circulation: If you've noticed that your skin is red after dry brushing, it usually isn't a cause for concern. The redness signals increased circulation and will pass after an hour or so.
I have read and accept the above Body Scrub Treatment Statements*

I agree, accept and understand the about statements
Preparing for your appointment
- Please bring all of the products you currently use to your appointment, and or fill them in below.
- Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will be added.
- Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin. This regimen must be used in order to continue treatments at skinSPArations, however not all products must be purchased on your first appointment.
- You will have the opportunity to receive 30% off your first purchase when you trade in ALL of your old products. After your first appointment, all product purchases are discounted 20% to skinSPArations.
Current skin care products you use at home. Include brand names and product names.*
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the aesthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release skinSPArations and/or the skin care professional from liability and assume full responsibility thereof.
I understand and agree*
Initial
I understand before/after photos will be taken for legal purposes and also grant permission to skinSPArations to use photos of my progress for marketing purposes on www.skinSPArations.com or other business listing pages such as Instagram.
To cancel an appointment please test 920-216-5338 or email skinSPArations@gmail.com at least 24 hours prior to your appointment.

Cancellations or Reschedule less than 24hrs notice will be subject to the following:
- First occurance 50% charge of service, after that 100% charge of service
- No Show or Missed Appointments 100% charge of service
I agree to the cancellation policy*
Initial
I agree to the photo release*
Client Full Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Should be Empty: