General Medical Aesthetics Release Form / Hold Harmless

I hereby consent to and authorize
(input name and business)
to perform the following treatment(s):

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the practitioner immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment), whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

I also release
(input name and business)
of any liability that may arise from this procedure.
Client Name (Printed):
Client Name (Signature):

Health History Intake Form

Date:
Name:
Date of Birth:
Address:
City:
State:
Age:
Phone:
Email:
Known allergies and reactions:
List current medications (topical & oral):
Please check any of the following that apply:
CancerDiabetesHysterectomyAIDS/HIVPsoriasisSpinal InjuryKeloid ScarringMenopauseHigh/ Low Blood PressureClaustrophobiaHormone ImbalanceHepatitis A/B/CRosaceaCold SoresBlood Clot DisorderEczemaImmune DisorderSkin Disease/DisorderVaricoseVeins/PhlebitisPacemaker/DefibrillatorThyroid DisorderBlush/Redden EasilyDepression/AnxietyBruise EasilyLupusFibromyalgiaCirculation DisorderMetal Implants/ PinsHeart Disease
Other:
1. Do you smoke?YesNo
2. Do you wear contacts?YesNo
3. Do you follow a restricted diet? YesNo
What is your daily consumption of Water (oz)?
Caffeine (oz)?
Alcohol (oz)?
Are you currently under the care of a physician or dermatologist?YesNo
If so, explain:
Any surgeries within the last 6 months?YesNo
If so, explain:
Any dermal injections/fillers with in the last 6 months? YesNo
If so, explain:
Are you using any products that contain Retin –A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product? YesNo
Have you used any of these products in the past 3 months? YesNo
If so, explain:
Have you ever had any allergic reaction to any skin products?YesNo
If so, explain:
Please list the brand and type of lip gloss/liner/stick that you have been using for the last 6 months:
Please list the brand and type of eye liner that you have been using for the last 6 months:
Please list the brand and type of foundation that you have been using for the last 6 months:
Please list the brand and type of eyebrow liner that you have been using for the last 6 months:
Please list the brand and type of daily moisturizer that you have been using for the last 6 months:
Please list the brand and type of nightly moisturizer that you have been using for the last 6 months:

Please list the brand and type of other cosmetics such as primer, skin glow etc... that you use on a regular bases, as some of the brands and products that you use may cause the producer not to take as it normally would. We want to make sure that everything is correctly addressed with our clients and that you fully understand that not everyone’s skin or body is going to get the results they want due to issues with our current and past use of other cosmetics that can cause damage to your skin, such as color stay products are more harm to the skin and will make PMU harder to take and will cause several follow up procedures to get the desired results.
Client Consent: I understand, have read and completed the 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 practitioner of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential.
The treatments I receive here are voluntary and I release
and from any liability and assume full responsibility thereof.

Name:
Date of Birth:
Address:
Phone:
Email :

Photographic Consent:
I consent to photographs being taken before, during and after each procedure. I agree to
these photos being stored electronically in my case file and will be used only with my written
consent for promotional purposes.

Patient Signature: Date:

Patch Test Waiver: (please initial where appropriate)

(A) I understand that a skin test can determine whether or not I will experience a reaction to
the products used within 48 hours prior to the treatment. However, I accept this will be
inconclusive as to whether I have an allergic reaction at any time in the future.
I therefore waive my option to an allergy test and wish to proceed with treatment.
(B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore release (practitioner name/company)
from liability related to any allergic reaction I may experience associated with either the application of the pretreatment cream or any other products used before, during and after my procedure, immediately or at a later date.

In case the case of an emergency , please contact:
Name:
Phone Number:
Relation: