FULL NAME

Date of Birth (DD/MM/YYYY)

Contact No

Email

GP DETAILS

Treatment Selection Treatment Selection

1. What treatments are you having today? 1. What treatments are you having today? ProSkin Pro Power Peel Micro needling Nano Infusion Dermaplaning Other IPL MelanoPRO

2. Within the last year, have you had any health problems that have affected or could affect your skin? 2. Within the last year, have you had any health problems that have affected or could affect your skin? Yes No

3. Are you prone to keloid scarring, blisters, or cold sores? 3. Are you prone to keloid scarring, blisters, or cold sores? yes No

4. List any medications, supplements, vitamins, diuretics, oral contraceptives, Isotretinoin, etc. that you take regularly.

5. Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments? 5. Do you have any other medical condition, or autoimmune diseases such as Lupus, contraindicated by your physician for advanced treatments? yes no

6. Do you wear contact lenses? 6. Do you wear contact lenses? yes no

7. Do you have metal implants, a pacemaker or body piercings? 7. Do you have metal implants, a pacemaker or body piercings? yes no

8. Do you have any allergies? 8. Do you have any allergies? yes no

If yes, please specify:

9. Do you have sinus problems? 9. Do you have sinus problems? yes no

10. Have you ever experienced claustrophobia? 10. Have you ever experienced claustrophobia? yes no

11. What are your specific concerns/challenges with your skin?

12. What skin care products are you currently using? 12. What skin care products are you currently using? Soap cleanser toner spf moisturizer masque exfoliant eye products other

13. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 2 weeks? 13. Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last 2 weeks? yes no

14. Have you been waxed within the last 1-2 weeks? 14. Have you been waxed within the last 1-2 weeks? yes no

15. Are you currently using any products that contain the following ingredients? 15. Are you currently using any products that contain the following ingredients? glycolic acid lactic acid any exfoliating scrubs Other Hydroxy Acids Vitamin A derivatives (i.e., Retinol) none of these above

16. Please specify if any of the following apply to you: 16. Please specify if any of the following apply to you: Pregnant trying to become pregnant lactating menstruating pre-menstrual

18. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? 18. Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks? yes no

17. Have you used retinol, tretinoin or any other prescription skin products within the last three months? 17. Have you used retinol, tretinoin or any other prescription skin products within the last three months? yes no

19. Do you have active cold sores? 19. Do you have active cold sores? yes no

20. Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks? 20. Have you received neurotoxin (Botox) injections within the past 2 weeks or other injectable procedures within the past 4 weeks? yes no

22. Do you experience redness, itching, or stinging on your skin? 22. Do you experience redness, itching, or stinging on your skin? yes no

21. Do you sunbathe or use tanning beds? 21. Do you sunbathe or use tanning beds? yes no

Precautions & Warnings Precautions & Warnings

Pro Power Peel Pro Power Peel

1. Skin may appear flushed following the treatment. 1. Skin may appear flushed following the treatment.

3. Avoid direct sun exposure for 2-3 weeks to prevent hyperpigmentation. 3. Avoid direct sun exposure for 2-3 weeks to prevent hyperpigmentation.

2. Peeling may begin within 2-3 days. DO NOT pick at loose skin, as this may cause discoloration. 2. Peeling may begin within 2-3 days. DO NOT pick at loose skin, as this may cause discoloration.

4. Avoid sweaty exercise on the day of treatment, along with steam rooms. 4. Avoid sweaty exercise on the day of treatment, along with steam rooms.

5. Avoid any type of exfoliating product until directed otherwise by Professional Skin Therapist. 5. Avoid any type of exfoliating product until directed otherwise by Professional Skin Therapist.

contradictions for pro power peel contradictions for pro power peel pregnant or nursing women open skin lesions or active cold sores recent resurfacing such as laser, microdermabrasion or chemical peel within 2 weeks use of isotretinoin currently or in the past six months severe rosacea or acne prone to post-inflammatory hyperpigmentation or keloid scars recent sun exposure history of diabetes received cosmetic injectables within 14 days

Microneedling Microneedling

2. Not for active acne, rosacea, or other inflammatory skin conditions. Not for skin with piercings in treatment area or open wounds. 2. Not for active acne, rosacea, or other inflammatory skin conditions. Not for skin with piercings in treatment area or open wounds.

1. Discontinue use of retinoid (Retin-A) and/or any form of skin treatment 3 days prior to procedure, under care and direction of a physician. 1. Discontinue use of retinoid (Retin-A) and/or any form of skin treatment 3 days prior to procedure, under care and direction of a physician.

3. Not to be administered for 6 months to 1 year after isotretinoin (Accutane) regimen. 3. Not to be administered for 6 months to 1 year after isotretinoin (Accutane) regimen.

4. Not for clients with facial outbreaks such as herpes simplex virus. Medication must be taken per doctor’s instructions. 4. Not for clients with facial outbreaks such as herpes simplex virus. Medication must be taken per doctor’s instructions.

5. Not for clients with metal allergies or skin allergies. 5. Not for clients with metal allergies or skin allergies.

6. Any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment, under the care and direction of a physician. 6. Any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment, under the care and direction of a physician.

8. Not for clients who have had dermabrasion, remodeling, deep chemical peels, or any surgical procedure on the treatment area within the previous 3 months. 8. Not for clients who have had dermabrasion, remodeling, deep chemical peels, or any surgical procedure on the treatment area within the previous 3 months.

7. For any recent face lift or eyelid surgery, seek advice from your surgeon regarding how soon you can receive treatment. 7. For any recent face lift or eyelid surgery, seek advice from your surgeon regarding how soon you can receive treatment.

9. Not for clients who have had neurotoxin injectable (Botox), or other injectables such as collagen, fat, or other methods of augmentation in the targeted area within 14 days. 9. Not for clients who have had neurotoxin injectable (Botox), or other injectables such as collagen, fat, or other methods of augmentation in the targeted area within 14 days.

10. Not for clients who have sunburned skin from the sun or tanning beds within previous 14 days. 10. Not for clients who have sunburned skin from the sun or tanning beds within previous 14 days.

11. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-treatment. 11. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-treatment.

12. Fitzpatrick skin types 4-6: pigment may darken prior to lightening. 12. Fitzpatrick skin types 4-6: pigment may darken prior to lightening.

13. You may experience redness for up to 3 days. 13. You may experience redness for up to 3 days.

14. You may experience inflammation, itching, and burning. 14. You may experience inflammation, itching, and burning.

15. Consult a physician if any irritation persists. 15. Consult a physician if any irritation persists.

contradictions for microneedling contradictions for microneedling history of hemophilia, irregular blood pressure, tuberculosis, liver function issues susceptibility to capillary ectasia due to steroid use for extended periods cardiac abnormalities, pacemaker, blood clotting problems blood thinning medication immunosuppression keloid scars history of eczema, psoriasis and other chronic conditions history of actinic (solar) keratosis, diabetes, raised moles or warts on targeted area scleroderma collagen vascular disease collagen vascular disease active bacterial or fungal infection; (i.e., cold sore) history of any type of cancer pregnant or nursing

Nanoinfusion Nanoinfusion

1. Discontinue use of retinoid (Retin-A) 3 days prior to procedure, under care and direction of a physician. 1. Discontinue use of retinoid (Retin-A) 3 days prior to procedure, under care and direction of a physician.

2. Not for active acne, rosacea, or other inflammatory skin conditions. Not for skin with piercings in targeted area or open wounds. 2. Not for active acne, rosacea, or other inflammatory skin conditions. Not for skin with piercings in targeted area or open wounds.

3. Not for clients with metal allergies or skin allergies. 3. Not for clients with metal allergies or skin allergies.

4. Any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment, under the care and direction of a physician. 4. Any medications that would affect the characteristics of the skin should be stopped for two months prior to treatment, under the care and direction of a physician.

5. Not for clients who have had neurotoxin (Botox) injectable, or other injectables such as collagen, fat, or other methods of augmentation in the targeted area within 14 days. 5. Not for clients who have had neurotoxin (Botox) injectable, or other injectables such as collagen, fat, or other methods of augmentation in the targeted area within 14 days.

7. Not for clients who have sunburned skin from the sun or tanning bed within previous 14 days. 7. Not for clients who have sunburned skin from the sun or tanning bed within previous 14 days.

6. No waxing, depilatory creams, or methods of hair removal to the targeted area for at least 5 days prior. No IPL/laser hair removal 14 days prior. 6. No waxing, depilatory creams, or methods of hair removal to the targeted area for at least 5 days prior. No IPL/laser hair removal 14 days prior.

8. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-treatment. 8. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-treatment.

9. You may experience redness between 1-3 days. 9. You may experience redness between 1-3 days.

11. Consult a physician if any irritation persists. 11. Consult a physician if any irritation persists.

10. You may experience inflammation, itching, and or burning. 10. You may experience inflammation, itching, and or burning.

12. Raised scars, lesions, or moles in the targeted area will not be treated. 12. Raised scars, lesions, or moles in the targeted area will not be treated.

13. Seek physician’s approval if you are pregnant or nursing. 13. Seek physician’s approval if you are pregnant or nursing.

contradictions for Nanoinfusion contradictions for Nanoinfusion keloid scars scleroderma active eczema, psoriasis, and other chronic condition flare up collagen vascular disease history of actinic (solar) keratosis, diabetes, raised moles or warts on targeted area active bacterial or fungal infection pregnant or nursing history of any type of cancer

Dermaplaning Dermaplaning

1. Discontinue products containing any exfoliating agents and active ingredients such as retinol 3 days before treatment. 1. Discontinue products containing any exfoliating agents and active ingredients such as retinol 3 days before treatment.

MelanoPro Peel System MelanoPro Peel System

2. Not for client with facial outbreaks such as herpes simplex virus. Medication must be taken per physician’s instructions. 2. Not for client with facial outbreaks such as herpes simplex virus. Medication must be taken per physician’s instructions.

3. Skins prone to post inflammatory hyperpigmentation (PIH): skin brightening home care pre and post service is advised. 3. Skins prone to post inflammatory hyperpigmentation (PIH): skin brightening home care pre and post service is advised.

contradictions for Dermaplaning contradictions for Dermaplaning current, inflamed acne lesions skin cancer active cold sores uncontrolled diabetes dermatitis open skin lesions open skin lesions use of Accutane currently or in the past six months use of prescription Retinol within the past 3 days

1. Avoid contact with the eyes, lips, and mucous membranes. In case of accidental contact, wash thoroughly with water. 1. Avoid contact with the eyes, lips, and mucous membranes. In case of accidental contact, wash thoroughly with water.

2. Not recommended for children under the age of 18. 2. Not recommended for children under the age of 18.

3. Do not use products with AHAs, BHAs, enzymes, exfoliants or Retinol during the treatment. 3. Do not use products with AHAs, BHAs, enzymes, exfoliants or Retinol during the treatment.

5. Avoid sun exposure during the home care program. 5. Avoid sun exposure during the home care program.

4. Make-up may be applied once any redness from the application of the Melanopro Peel System has stopped. 4. Make-up may be applied once any redness from the application of the Melanopro Peel System has stopped.

6. History of diabetes. Ensure there is no current active health concerns with healing or any complications with peels in past services. 6. History of diabetes. Ensure there is no current active health concerns with healing or any complications with peels in past services.

contradictions for MelanoPro Peel System contradictions for MelanoPro Peel System This system is not advised for those with highly sensitive skin or those who have skin conditions such as rosacea, eczema, psoriasis, etc. Not for use on those that have sunburned skin. Not for use on pregnant or nursing clients. Not for use on those with active cold sores. Not for use on those with open skin lesions. Not for those currently using Isotretinoin in the past 6 months. Not for those prone to keloid scars. Not for use on those who have had injectables in the past 14 days.

IPL IPL

2. Discontinue photosensitizing medications, such as Accutane (Isotretinoin), at least 6 months before treatment. Discontinue medications such as Retin-A, Renova, and Tazorac 3-7 days before treatment. 2. Discontinue photosensitizing medications, such as Accutane (Isotretinoin), at least 6 months before treatment. Discontinue medications such as Retin-A, Renova, and Tazorac 3-7 days before treatment.

1. Not for clients who have excessively tanned or sunburned skin from the sun, tanning beds, or tanning creams within previous 4 weeks. 1. Not for clients who have excessively tanned or sunburned skin from the sun, tanning beds, or tanning creams within previous 4 weeks.

4. Shave dark hair or prevalant vellus hair 12-24 hours before treatment. 4. Shave dark hair or prevalant vellus hair 12-24 hours before treatment.

3. Discontinue waxing, chemical depilatories and chemical peels on the treatment area within 1-2 weeks of treatment. 3. Discontinue waxing, chemical depilatories and chemical peels on the treatment area within 1-2 weeks of treatment.

7. You may experience redness for up to 3 days. 7. You may experience redness for up to 3 days.

5. IPL is not recommended for melanin-rich skin (Fitzpatrick skin types 4 and higher). Please consult your physician for approval to receive treatment. 5. IPL is not recommended for melanin-rich skin (Fitzpatrick skin types 4 and higher). Please consult your physician for approval to receive treatment.

6. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-procedure. 6. Avoid sweaty exercise, sauna, steam, and sun exposure for 3 days post-procedure.

8. You may experience tightness, inflammation, itching and burning. 8. You may experience tightness, inflammation, itching and burning.

9. Pigmentation may appear darker after treatment. Avoid picking or scrubbing skin for 1-2 weeks, as it can cause scarring. 9. Pigmentation may appear darker after treatment. Avoid picking or scrubbing skin for 1-2 weeks, as it can cause scarring.

10. Consult a physician if any irritation persists. 10. Consult a physician if any irritation persists.

contradictions for IPL contradictions for IPL epilepsy or history of seizures lupus use of photosensitizing medications (including some antibiotics) use of St. John’s Wort within the past 3 months areas with permanent make-up or tattoos (including cosmetic) vitiligo pregnant or nursing cancer history of keloid scars severe dermatitis, active inflammatory acne or eczema on targeted area active infections (e.g. herpes simplex) use of Accutane currently or in the past six months use of diabetes medication use of Vitamin A or hydroxy acids within the past 3 days presence of a pacemaker presence of surgical metal pins or plates under targeted area use of blood-thinning agents (i.e. Aspirin, Ibuprofen, Aleve) within the past week

Declaration Declaration I understand that failure to disclose information requested above may result in adverse side effects from treatment(s) received and therefore I accept full liability/responsibility for the information given.

Technicians name

DD/MM/YYYY