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Name

First

Last

Date of Birth

Phone

Email

Address

Address Line 1

City

State / Province / Region

Treatment

Chemical Peel
Microneedling
Dermaplaning
24K Gold Facial

Please fill out only the selection relevant to the treatments you are interested in.

date): history salicylic

1: Do you have any known allergies?

Yes
No

2: Are you currently taking any medications?

Yes
No

4: Are you pregnant or breastfeeding?

Yes
No

5: Have you used Accutane or any other prescription acne medications within the last year?

Yes
No

6: Do you smoke or use tobacco products?

Yes
No

Have you been informed about pre-treatment guidelines for each treatment?

Yes
No

If yes, please acknowledge the following instructions:

For Chemical Peel: Avoid excessive sun exposure, discontinue retinoids and exfoliants for at least one week prior.

For Microneedling: Refrain from tanning, sun exposure, and avoid retinoids or exfoliating products 3-5 days prior.

For Dermaplaning: Avoid waxing, threading, and harsh exfoliants on the treatment area for at least 1-2 weeks prior.

Acknowledgment & Consent:

I, _________, confirm that I have provided accurate information in this form to the best of my knowledge. I understand the potential risks of chemical peel, microneedling, and dermaplaning treatments and agree to follow all pre- and post-care instructions provided by my aesthetic practitioner.

Date

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Chemical Peel:

Microneedling:

Dermaplaning:

24K Gold Facial Section:

Acknowledgment & Consent:

This combined template should cover the necessary information and risks for each treatment, ensuring clients are well-prepared and informed.