An intuitive space specializing in advanced skincare techniques with a holistic skin- C A R E approach. PROCELL MICROCHaNNELING IMPROVE: ACNE, FINE LINES, HAIR GROWTH, HYPERPIGMENTATION, SUN-DAMAMGE, TONE & WRINKLES Learn more Good Skin Club SKIN & SUGARING The membership you never knew you needed(Shhh, memberships also include monthly special perks just for you…)10%-20% off ANY additional services**10%-15% off products/skincare**(1) free skincare product on your birthday20%-40% off one friend/family member per month** (New Client only)**Depending on membership Join Good Skin Club Pamper your skin with products intentionally selected and results driven Book Now Acne + Anti-aging + hyperpigmentation clinic Book Facials & Scalp Care Book SUGARing (HAIR REMOVAL) Book NEW CLIENTS- CONSENT CONSULTATION FORM New Client Consent Consultation Form Date MM DD YYYY Name * First Name Last Name DOB Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Message * Does your job require you to work outdoors? Referred by What would you like to achieve from your treatment today? Have you ever had a facial treatment before? Yes Yes No When? Does your job require you to work outside? Yes No Which of the following best describes your skin type? (Please select one) I Creamy complexion. Always burns easily, never tans II Light complexion. Always burns, tans slightly III Light/Matte complexion. Burns moderately, tans gradually IV Matte complexion. Seldom burns, always tans well V Brown Complexion. Never burns, deeply pigmented VI Black complexion. Never burns, deeply pigmented Do you have any special skin problems or concerns pertaining to your face or body? Specify Have you ever had chemical peels, laser, or microdermabrasion? Yes No In the last month- Yes No Do you use Retin-A, Remova, Adapalen, Hydroxyl Acid or Retinol/vitamin A derivative products? Yes No Describe Have you used any of these products in the last 3 months? Yes No Have you used an acne medication? No Yes What is the name of the acne medication? List the name of products (toner, soap, cleanser, exfoliator, scrubs, etc)you use What skin care products are you currently using? (List brand where known) Have you used any of the following hair removal methods in the past six weeks? Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories What areas of concerns do you have regarding your skin: (Please check all that apply) Breakouts/acne Blackheads/whiteheads Excessive oil/shine Rosacea Broken capillaries Redness/ruddiness Sun spot/liver spot/brown spot Uneven skin tone Sun damage Wrinkles/fine lines Dull/dry skin Flaky skin Dehydrated Other Eyes Dehydrated Wrinkles Puffiness Dark cirles Other Lips Dehydrated Cracked/chapped lips Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain) Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs Other known allergic reaction- What SPF do you use on your face? How often/when? Have you had Botox, Restylane or Collagen injections? Please specify including date- Are you taking oral contraceptives? Specify- Any changes to or from your contraceptive treatment? If so, what and when- Are you pregnant? No Yes Are you lactating? No Yes Any menopause problems? No Yes Are you undergoing any hormone replacement therapy? Specify- Please include any other information you would like to share I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Beauty Shamanista of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products. * Signature- "I Accept" using any device, means or action, you consent to the legally binding of this form. You further agree that your signature on this document (hereafter referred to as your E-Signature) is as valid as if you signed the document in writing. Date MM DD YYYY Thank you!
