WaiverElectronic- a global online beauty waiver software company.
Skin History and Consent Form
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Health Related Questionnaire
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*Remove contacts if eyes are sensitive or if having a microdermabrasion
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*If so, your service may have to be rescheduled
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*May increase sensitivity
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Skin Care Questionnaire
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Have you had any of the following:
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What products/brands are you using?
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Skin Condition
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Precautions
The Skin Occasions Treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of the skin.
Your participation in your skin care treatments will determine the outcome. It is important that you strictly adhere to your home care products that your esthetician has recommended.
No guarantee is expressed or implied as to the precise results, peeling times, or discomfort.
Depending on the treatment, you may experience some temporary stinging or warm flushing. This will fade within 5 minutes. During the next few hours, you may experience some tightening of the skin, which may last for several days.
For most patients, a light flaking begins within 48 hours. It is impossible to pre-determine how much peeling will occur. The shedding process usually subsides within 2-3 days.
Please Initial (Please Read Carefully)
Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as: pregnancy, recent facial surgery, allergies, tendency to cold sores/fever blisters, or use of topical and/or oral prescription medications.
I understand there may be some degree of discomfort such as stinging, pin-pricking sensation, heat or tightness
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, ect.
I understand I may or may not actually peel and that each case is individual. I understand that the amount of the peeling does not correlate with degree of improvement.
I understand this treatment is a cosmetic treatment and that no medical claims are expressed or implied.
I understand that to achieve maximum results, I may need several treatments.
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 esthetician whom performed the treatment.
I agree to refrain from tanning in tanning beds or outdoors while I am undergoing treatment and during the 14 days prior to, and following the end of the treatment.
I understand that extended direct sun exposure is prohibited while I am undergoing treatment, and the daily use of sunscreen protection with a minimum of SPF 30 is mandatory.
I have not had any other chemical peel of any kind within 14 days of this treatment. I further understand I cannot have another chemical peel within 14 days of this treatment at this location or any other location.
I understand I should follow my esthetician’s recommendations for post-treatment skin care to minimize side effects and maximize results.
Initial Here
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Consent (Please Sign)
I hereby give my consent and authorization voluntarily and release Skin Occasions staff from any claims, implied or stated that I have or may have in the future with this treatment, regardless of result. I am stating that the treatment and precautions above have been explained to me in detail and that I fully understand.
