Consent Forms Client Intake FormClient Intake FormFirst NameLast NameAddressAddress Line 1Address Line 2CityStateZip CodeBirthdatePatient Gender- Select -MaleFemaleOthersPhone numberOccupationEmergency Contact & Phone NumberWho is your primary care doctor: Where is your primary care doctor located ? Are you allergic to anything? Yes NoList of allergiesDo you smoke? Yes NoHow many years did you smoke?Do you drink alcohol? How did you hear about us?- Select -Drove byMall AdvertisementGoogleYelpFacebookInstagramReferralAre you currently using any topical prescription product? (Retin-A, Differin, Tazorac, etc)Are you using glycolic or alphahydroxy acids, salicylic acid, or skin bleaching creams? Yes NoHave you ever had any reaction to any products or anything you have put on your face? Yes NoIf yes, please explain in detail if possibleHave you had skin cancer? Yes Noif so, when?Are you currently pregnant or breastfeeding? Yes NoCurrently under a lot of stress? Yes NoAre you currently using birth control? Yes NoDo you have any allergies or sensitivities to cosmetics, foods, or drugs? if so please listif so, what?Are you taking any medications? Yes Noif so, what?Please indicate any of the following that apply to you: Depression Anixiety Sinus Low Blood Pressure Herpes Fever Blisters/Cold Sores Pacemaker Headaches/Migraines HIV Sinus Urinary / Kidney Problems Diabetes OtherOtherHow would you describe your skin?Please indicate which of the following concerns you have about your skin? Acne Hyperpigmentation Oily Dry/Dehydrated Sun Spots Aged Skin Textured Dull Redness ScarringUpload images of your concerns if you like (both sides, and front facing)Choose File How would you describe your daily eating habits?What is your current skin care regimen? Please list the products you are usingWhat skincare/cosmetic treatments have you had in the past 90 days, please give date as wellWhat are you goals for this treatment?Based on your concerns, are you ready to commit to a new home care regimen to achieve results at your appointment? Yes, Im ready to revamp my routine! No, just looking for one time treatmentDo we have your permission to use your treatment photos for educational purpose, website before & after or social media content? Yes NoWould you like a silent appointment? There is no wrong answer, this is your time! Yes, Im here to zen out! No, I'd love to chat!Do you have a music preference? (LoFi, R&B, Ocean Sounds, Jazz, Nature Sounds, Acoustic etc.)- Select -Lo FiAcousticInstrumentalOcean SoundsR&BJazzBluesDoesn't matterI understand that results will vary among individuals. I understand that although I may see a change after my first treatment, I will likely require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that microneedling treatment is not permanent as natural degradation will occur over time. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. This consent form is valid until all or part is revoked by me in writing. All services and products are non-refundable. I acknowledge that I have been candid in revealing any condition which might have an effect on this treatment, such as: pregnancy, medication, previous or recent skin surgery or treatment, skin cancer, cold scores/fever blisters, allergies, use of Retin-A, Accutane, Differin or hormones and recent sun/tanning bed exposure, along with listing all products that I am currently using. If checked yes, I hereby grant SKIN CABINET, its representatives and employees, permission to use and/or publish photographs or videos of myself on its social site, or website. I understand and agree that these materials will become the property of SKIN CABINET. I hereby authorize SKIN CABINET to use images taken or video for purposes of publicizing their treatments or for any other purpose. Signature Sign Here I have read the above paragraphs and agree to the Terms and Conditions and Spa PoliciesSave & ResumeSubmit Form Dermaplane ConsentDermaplane Consent Form I understand that Dermaplaning is the process of removing superficial layers of dead skin cells and vellus hair on the skin’s surface by the use of a sterile blade. Initial I understand that there may be unforeseen risks with Dermaplaning such as nicking, scraping or abrading the skin with the blade. Initial I understand that possible side effects of the treatment area can include mild redness of the skin, irritation and dryness. Initial I understand that if a chemical peel is part of this treatment, that the sensation and penetration of the peel will be enhanced. This may cause minor skin irritation, mild discomfort, and tenderness, lightening or darkening of the skin, peeling and activation of cold sores. Initial I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc. Initial I understand that in order to see significant results these treatments need to be done in a series and in combination with using active ingredient skin care products. Initial I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of a daily sun block protection is mandatory. Initial I am not using Retin A®, or other retinol derivatives, products containing Alpha Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products at least 3 days prior to treatment. Initial I will contact my practitioner if I have any questions or concerns about my treatment. Initial I have been advised not to exercise after my treatment. Initial I agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have a bearing on this procedure. I am over 18 years of age. Signature Sign Here First NameLast NameDateSubmit Form Microneedling Consent Form MICRONEEDLING CONSENT FORM Being fully informed about your condition and treatment will help you make the decision whether or not to have a microneedling treatment. This disclosure is not to alarm you but to better inform you so that you may withhold your consent for this treatment (INITIALS)Description of the ProcedureMicroneedling treatment allows for controlled induction of the skin’s self-repair mechanism by creating micro-”injuries” in the skin, which triggers new collagen synthesis, yet does not pose the risk of permanent scarring. The result is smoother, firmer and youthful-looking skin. Microneedling procedures are performed in a safe and precise manner with the use of a single use sterile cartridge. The procedure is normally completed within 30-60 minutes, depending on the required treatment and anatomical site. (INITIALS)Side Effects After the procedure, the skin will be red and flushed in appearance in a similar way to moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on the area being treated. This will diminish greatly after a few hours following treatments and within the next 24 hours the skin will be completely healed. After three days there is barely any evidence that the procedure has taken place. (INITIALS)Contraindications Microneedling treatment is contraindicated for patients with: keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or haemostatic dysfunction, active bacterial or fungal infection. (INITIALS)Precautions & Warnings Microneedling treatment has not been evaluated in the following patient populations, as such, precautions should be taken when determining whether to treat: scars and stretch marks less than one year old; women who are pregnant or nursing; keloid scars; patients with history of eczema, psoriasis and other chronic conditions; patients with history of actinic (solar) keratosis; patients with history of herpes simplex infections; diabetics or patients with wound-healing deficiencies; patients on immunosuppressive therapy; and skin with presence of raised moles or warts or targeted area. (INITIALS) Patient Consent I understand that results will vary among individuals. I understand that although I may see a change after my first treatment, I will likely require a series of sessions to obtain my desired outcome. The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I am aware that microneedling treatment is not permanent as natural degradation will occur over time. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. This consent form is valid until all or part is revoked by me in writing. All services and products are non-refundable. (INITIALS)I understand to all the information above Sign Here First NameLast NameDateSubmit Form PeelsPeelsIn order to achieve the best results possible from your peel treatment it is important that you read and understand the following instructions. If you have any questions regarding these instructions please contact your Skin Specialist/Physician for clarification. I understand that if, for any reason, I stop or interrupt the prep procedure I must contact my Skin Specialist immediately and notify them of any changes to my skin care regimen. My appointment or type of peel may need to be changed or rescheduled. I agree to STOP, DISCONTINUE or NOT HAVE ANY OF THE FOLLOWING TREATMENT I understand that if, for any reason, I stop or interrupt the prep procedure I must contact my Skin Specialist immediately and notify them of any changes to my skin care regimen. My appointment or type of peel may need to be changed or rescheduled. I agree to STOP, DISCONTINUE or NOT HAVE ANY OF THE FOLLOWING TREATMENT Discontinue one week prior to treatment: Anti wrinkle injections, Home Needling, Prescription and or topical Retin ADiscontinue Two weeks prior to treatment: Waxing, bleaching or hair dying any areas to be treated Depilatory use in any treated area Electrolysis on any treatment area IPL/Laser Hair removal treatments IPL/Laser Skin Rejuvenation (Only prior to very superficial peels) Sun exposure to area to be treated Facial treatments of any kind including any AHA, BHA or Vitamin A treatments Microdermabrasion / Epidermal Leveling Dermal Fillers Discontinue three-six months prior to treatment: Microneedling Fractional Ablative Laser Resurfacing TCA or Phenol Deep Peeling Facelift SurgeryCan you avoid outdoors for the next 7-10 days Yes NoDo you plan to avoid participating in vigorous exercise in the next 7 days? Yes NoSelect skin concern you are seeking improvement on? Acne Texture Hyperpigmentation Aging Signature Sign Here First NameLast NameDateSubmit Form MicrocurrentMicrocurrentCONTRAINDICATIONS PACEMAKER EPILEPSY HISTORY OF SEIZURES METAL PLATES PINS IN THE AREA OF TREATMENT DIABETES CANCER RECENT SURGERY PHLEBITIS/THROMBOSIS SPINE PROBLEMS PREGNACY RECENT CHILDBIRTH *ANY OTHER MEDICAL PROBLEM WILL REQUIRE A PHYSICIAN'S APPROVAL I am not pregnant or breast feedingInitial I do not have any known malignancy, autoimmune disorder, neurological or neuromuscular diseaseInitial I do not have any metal implanted devices. These include pacemakers, defibrillators, metal heart valves, large metal dental implants, artificial metal joints, metal platesInitial I do not currently have a cold sore/fever blister or canker sore. If I have a history of these, I have been advised to take necessary medication, such as Valtrex, to prevent an outbreak.Initial I do not have a history of thrombosis or any blood clotting disorders.Initial I do not have epilepsy or a seizure disorderInitial I have no known heart conditionsInitial I understand that:This is a cosmetic treatment and that no medical claims are expressed or implied.Initial To achieve maximum results, several treatments are required.Initial 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.Initial Signature Sign Here First NameLast NameDateSubmit Form Hydrafacial ConsentHydrafacial ConsentHydrafacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person.What to expect: Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. Client experiences may vary. Some clients may experience a delayed onset of these symptoms. You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.First NameLast NameDo you have active inflamed acne or infection on treatment area? Yes NoDo you have an open lesion or cold sore? Yes NoDo you have active sunburn in treatment area? Yes NoSkin conditions such as eczema, dermatitis, or rashes on treatment area? Yes NoAn autoimmune disease such as lupus? Yes NoA viral concern such as HIV or hepatitis? Yes NoAnticoagulants Therapy? Yes NoMelanoma or lesions suspected of malignancy? Yes NoPregnancy or Lactation? Yes NoNeurological disorders such as epilepsy (LED Lights) Yes NoInfection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage) Yes NoUsed Accutane, topical medications or antibiotics Yes NoCrohn’s Disease (Lymphatic drainage) Yes NoHyperthyroidism (Lymphatic drainage) Yes NoDeep Venous Thrombosis (Lymphatic drainage) Yes NoHad aesthetic fillers, injectables or laser treatments within last two weeks? Yes NoBy signing this consent, I understand that I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre- and post-treatment. Photos may be taken before, during and after the HydraFacial treatment. Photos may be used for education, promotion or advertising purposes. The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at SKIN CABINET By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form Is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history.Signature Sign Here Date Submit Form
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