Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Birthday

MM

DD

YYYY

Do you ever experience breakouts? *

Yes

No

Do you have a history of chronic acne? *

Yes

No

Do you have chronic skin sensitivity? *

Yes

No

Do you have a history of cold sores? *

Yes

No

Have you ever had facial peels, laser rejuvenation or microdermabrasion / dermabrasion? *

Yes

No

Have you used facial waxes or depilatories in the past 3–4 weeks? *

Yes

No

Have you ever taken Accutane? *

Yes

No

Do you use Retinol creams, Retin A or other topical oral skin medication? *

Yes

No

Do you wear contact lenses? *

Yes

No

Do you work / play in the sun? *

Yes

No

Do you consider your skin to be sensitive? *

Yes

No

Do you use an SPF? *

Multiple times a day

Daily

Weekly

Occasionally

Never

Do you use tanning beds? *

Often

Occasionally

Never

Are you pregnant?

Yes

No

Are you lactating?

Yes

No

Do you experience premenstrual breakouts?

Yes

No

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy (if so, consult your physician prior to treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications such as: trentinoin, Retin-A, isotrentinoin, Accutane, Differin, Tazorac, Avage, EpiDuo or Ziana. *

I accept

I understand there may be some degree of discomfort as stinging, pin-pricking sensation, heat or tightness. *

I accept

I understand 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. *

I accept

I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied. *

I accept

I understand that to achieve maximum results, I may need several treatments. *

I accept

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact the physician/clinician who performed the treatment. *

I accept

I agree to refrain from tanning beds while I am undergoing treatment and during the 7 days prior to and following the end of treatment. It is recommended that this practice be discontinued due to the increased risk of skin cancer and signs of aging. *

I accept

I understand that extended direct sun exposure is not recommended while I am undergoing treatment, and the daily use of sunscreen protection with a minimum of SPF 30 is recommended. *

I accept

I have not had a chemical peel of any kind within 14 days of this treatment. I understand I cannot have a chemical peel within 14 days of this treatments, whether it is performed at this location or any other location. *

I accept

I understand that I should follow my clinician’s recommendations for post-procedure skin care to minimize side effects and maximize results. *

I accept

Date *

MM

DD

YYYY