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Which of the following would you like to improve?
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Have you ever had any of these conditions?
RosaceaSkin inflammatory disorderEmbolismThrombosis/PhlebitisMelanomaCold SoresEpilepsyLight SensitivityStroke/TIA
Any other health conditions not listed, or anything we should know about?
If you have a history of skin malignancies, please list the kind and date.
What are your skincare goals?
Although every precaution will be taken to ensure your safety and wellbeing before, during and after your microcurrent treatment, please be aware of the following information and possible risks. Please check each item indicating that you have read and understand.
I understand that the use of Botox, Juvederm, Restylane, and any other injectable must be disclosed prior to treatment.
I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk.
I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations
I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure.
I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.
I understand that it is imperative to my health that I disclose all of the information requested on this form.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
So that we can best serve all our valued clients, please acknowledge that you understand the following policies.
ARRIVAL TIME Please plan on arriving 5 minutes prior to your appointment. If you arrive after your appointment time, your service could be shortened due to your late arrival.
CHANGING YOUR APPOINTMENT 24 hours notice is required to reschedule or cancel an appointment. If you are unable to give 24 hours notice, we will do our best to fill your appointment. However, if we are unable to do so, you will be charged a late cancel fee up to $50.
I understand that there are certain risks associated with facial services. I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the procedure we have discussed, and will hold Spa 98 harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. *Enter your full name as your signature signifying that you have read and agree.
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