Client Form

Date

Name

First

Last

Phone

Email

Within the last year, have you had any health problems that have affected or could affect your skin?

Yes
No

If yes, please specify (health problems that have affected or could affect your skin):

List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, isotretinoin, etc. that you take regularly:(If none ,please write N/A)

Do you wear contact lenses?

Yes
No

Do you have metal implants, a pacemaker or body piercings?

Yes
No

Do you have any allergies?

Yes
No

If yes, please specify (allergies):

Do you have sinus problems?

Yes
No

Have you ever experienced claustrophobia?

Yes
No

What are your specific concerns/challenges with your skin?

What skin care products are you currently using?

Have you had chemical peels, microdermabrasion or any resurfacing treatments within the last three months?

Yes
No

Have you been waxed within the last 72 hours?

Yes
No

Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?

Yes
No

Are you currently using any products that contain the following ingredients?

Please identify any of the following apply to you:

I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Signature

Clear Signature

Please sign

I want to get a Pro power peel treatment today

Yes
No

This treatment is designed to resurface the skin. You may experience temporary burning, itching, or stinging. Please inform your professional skin therapist if you experience these sensations. Your full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort.

Have you received a cosmetic (non-surgical) procedure such as laser treatment, IPL, etc. within the last 6 weeks?

Yes
No

Do you have active cold sores?

Yes
No

Have you received Botox or other injectable procedures within the past week?

Yes
No

Do you sunbathe or use tanning beds?

Yes
No

Do you experience redness, itching, or stinging on your skin?

Yes
No

I release and waive any claims against Dermalogica, LLC and Asal skin Lounge, their affiliates and subsidiaries, and their respective officers, directors, agents, servants and employees, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel treatment:

I read and agree

Post-Care instructional sheet *

I acknowledge that post-care instructions were provided to me and I had the opportunity to ask questions, and I understand the instructions.

Pro Power Peel treatment consent date

Signature

Clear Signature

Please sign

Esthetician Note section