Medical History
Check all that apply:
Medication History
Check all used within past 4 months to current
Self Skin Evaluation
Overall, do you describe your skin as (check all that apply):
Please list any other medications you're currently taking:
Please list any known allergies or sensitivities:
Please list any other illnesses/conditions you are currently being treated for by a medical professional, or any other medical condition we should be aware of (fever, common cold, infection, etc.):
What is your menstrual cycle due date? Allow five days for menstrual cycle. Because of water retention and your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.
What skin care products do you use?
Have you ever had a topical skin reaction? If so, what did you react to?
Policy Disclosures
Please check each policy to state that you read and understand the policy:
I understand that any missed/cancelled appointments without 24 hour notice will result in charge of the full amount of the service and will be charged to the credit card I have provided on file (non-members), gift card, or my Valley membership (members only).
I have read and understand the above
I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically
I have read and understand the above
I take it upon myself to keep the esthetician updated on my physical health
I have read and understand the above
I understand that if I have any concerns, I will address these with my esthetician.
I have read and understand the above
I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions.
I have read and understand the above
Contraindications
Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for advanced facial treatment and must be disclosed prior to treatment:
- Active infection of any type, such as Herpes simplex virus or flat warts.
- Active acne
- Sunburn
- Uncontrolled diabetes
- Eczema, dermatitis
- Recent use of topical agents such as glycolic acids, alphahydroxy acids and Retin-A
- Any recent chemical peel procedure
- Skin cancer
- Vascular lesions Oral blood thinner medications
- Rosacea
- Tattoos (not effective)
- Pregnancy
- Use of Acutane within the last year
- Family history of hypertrophic scarring or keloid formation
- Telangiectasia/erythema may be worsened or brought out by skin exfoliation
- Epilepsy
- Metal implants/braces
- Pacemakers
- Heart conditions
I have read and understand the above
Post-Treatment / Home Care
Aerobic exercise or vigorous physical activity should be avoided until all redness has subsided. Direct sunlight exposure is to be completely avoided immediately following the treatment (including any strong UV light exposure and tanning beds). If some sun exposure cannot be avoided, first apply sunscreen with an SPF of 30 or greater. Although sunscreen should be a part of your daily skin care, for a minimum of two weeks, a sunscreen with at least a SPF of 15 must be applied.
Cleanse your face with water or a mild soap substitute twice daily followed by a mild sunscreen (minimum SPF 30). If a site other than the face is treated, you only need to cleanse once daily, followed by sunscreen. In the event that you may have additional questions or concerns regarding your treatment or suggested home product / post-treatment care, you must consult your esthetician immediately.
You may experience excessive dryness and/or peeling between sessions, which may or may not be normal. Always check with the esthetician if you have any concerns after the treatment. More sensitive skin may experience some redness after the first couple of sessions. This normally goes away after 2 to 3 hours.
I have read and understand the above
Peel Consent
I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my esthetician. My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne condition. I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to inform the esthetician immediately if I have concerns or am overly uncomfortable during treatment or after I return home. I agree that I am willing to follow recommendations by my esthetician for home care. I agree to use a moisturizer and sunscreen specifically recommended by my esthetician and I acknowledge that I have been informed of the possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my professional immediately. I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations.
I have read and understand the above
Informed Consent
Please sign to state that you read and understand the policy
I give permission to my esthetician to perform the procedures we have discussed. I agree to hold harmless the The V Spa, its employees and agents for any liability that may result from this treatment and/or for any of my conditions that were present but not disclosed at the time of this service. 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 esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I understand that estheticians do not diagnose illness, disease, or other medical, physical, or emotional disorders or prescribe medical treatment or pharmaceuticals. It has been made clear to me these services are not a substitute for medical examination or diagnosis and that I am responsible for consulting a qualified physician for any physical ailment I might have. 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 agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I also affirm that I am at least 18 years of age, or have parental consent to receive my services today (if under 18, parent or guardian signature must be present).
Please check all consent and disclosure checkboxes.
Your form has been successfully submitted. Thank you!
