FACIAL CONSENT FORM

Your treatment may include the following: enzymes, acid peels, dermabrasion, dermaplaning, extractions, microcurrent, electrical muscle stimulation (EMS), galvanic, high frequency, ultrasonic, LED light therapy, oxygen therapy and other treatment modalities as necessary.

First name

Last name

Date of Birth

Do you have any skin concerns today?:

Medical History

Are you Pregnant or Nursing?

Yes

If Yes, how many weeks?

Please list any allergies

Other illnesses:

Please list any Surgeries, including plastic surgery:

Please list your Current Oral & Topical Medications

Are you or have you been on Accutane within the past 6 months?

Yes

Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5-7 days?

Yes

Have you had Botox or Dermal Fillers?

Yes, less than 2 weeks ago

Yes, at least 2 weeks ago

If you have received any cosmetic injectables within 2 weeks of your appointment, please contact us at yherwellness@gmail.com to reschedule your appointment.

Does your skin get red or irritated easily?

Yes

Do you wear Contact Lenses?

Yes

Are you Claustrophobic?

Yes

Alcohol Consumption

I don't drink

1-2 glasses/week

3-4 glasses/week

5+ glasses/week

Do you smoke?

Yes

Please list any skincare products that you are currently using:

Please read ALL of the following statements carefully and indicate your understanding and acceptance: *

I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, dermabrasion, dermaplaning, extractions, microcurrent, electrical muscle stimulation( EMS), galvanic, high frequency, ultrasonic, LED light therapy, oxygen therapy and other treatment modalities as necessary.

I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, multiple treatments are necessary and I need to follow the maintenance home protocol. I understand that treatments results will vary from person to person.

I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual.

I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness.

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 a member of the Y'Her Esthetics & Wellness Spa staff.

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory.

I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Retin-A (retinol) or any contraindicated topical ingredients/products should be discontinued five to seven days prior to the treatment with exception of Accutane which must be discontinued for 6-12 months prior.

I have not received cosmetic injectables such as Botox or Dermal fillers ( or any cosmetic injectables ) within the past 2 weeks. I understand that I must wait at least 2 full weeks before any facial treatment can be performed.

PHOTOGRAPHS: I give permission for photographs to be used by the Y'Her Esthetics & Wellness Spa staff for monitoring my treatment progress.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Y'Her Esthetics & Wellness Spa of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I do not currently have, nor have experienced symptoms such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, runny nose, sinus congestion, nausea or vomiting, diarrhea, or new loss of taste or smell within the past 14 days.

I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release Y'Her Esthetics & Wellness Spa LLC and any of its employees/staff against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.

By my electronic signature below, I give consent to receive treatments at Y'Her Esthetics & Wellness Spa LLC and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or Y'Her Esthetics & Wellness Spa LLC for any services rendered.

Date

Your Signature

Thanks for submitting! See you soon.

FACIAL CONSENT FORM

Medical History

Please read ALL of the following statements carefully and indicate your understanding and acceptance: *

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