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Skin Care Consent Form 

Please complete this form prior to your appointment so your therapist may review it in advance.
If you have any questions, feel free to reach out and we will respond as soon as possible.

All submitted forms are securely stored and protected in accordance with HIPAA regulations to ensure your privacy and confidentiality.

Skin Care Consent Form

Spa Day With Gwen

 Guendelyn Ramirez, LE # 1977827

 Remote Services/ Out-of-Establishment Services

Client's Contact Information:

Birthday
Month
Day
Year

Health Information:

Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Yes
No
Any recent surgery, including plastic surgery?
Yes
No
Have you had any piercings, tattoos, or permanent cosmetics?
Yes
No
Have you ever had a body spa treatment before?
Yes
No
Has your physician discussed concerns about raising your body temperature?
Yes
No
Do you smoke?
Yes
No
Do you follow a restricted diet?
Yes
No
Do you consume:
Do you follow a regular exercise program?
Yes
No
What is your stress level?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
Yes
No
Have you used any of these products in the last 3 months?
Yes
No
Have you used an acne medication?
Yes
No
Do you form thick or raised scars from cuts or burns?
Yes
No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Yes
No
Do you experience any problems sleeping?
Yes
No
Do you wear contact lenses?
Yes
No
Have you been exposed to the sun or used a tanning bed in the last 48 hours?
Yes
No
How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
Do you have any metal implants or wear a pacemaker?
Yes
No
Have you ever experienced claustrophobia?
Yes
No
Do you suffer from sinus problems?
Yes
No
Have you ever had an adverse reaction after using any skin care product? (Please circle any that apply)
Have you ever had an allergic reaction to any of the following? (Please select any that apply and explain

Female Client's Only

Are you taking oral contraceptives?
Yes
No
Any recent changes to or from your contraceptive treatment?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
Any menopause problems?
Yes
No

Consent for Treatment:

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 esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

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Date
Month
Day
Year
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