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Consultation Form

Please complete this form for treatment candidacy.

Do your job or hobbies require that you work outdoors?
Do you have an event or vacation that you are attending in the near future?
Do you have any special skin problems or concerns? (lesions, cancer, discolorations, etc.)
Are you interested in learning more about our medical grade skincare line?
Have you ever used a Retinol, Accutane, or Hydroquinone?
Have you recently used any self-tanning lotions, creams or treatments?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Have you used any of the following hair removal methods in the past 6 weeks?
Have you experienced Botox, Restylane or Collagen injections?
Have you had any of the following esthetic treatments in the past 6 weeks?
Have you ever had microblading or cosmetic tattoo treatment?
Do you have any surgical implants?
Do or have you ever experienced herpes/cold sores around mouth or eyes?
Do you drink at least 20oz of water daily?
Are you pregnant and/or nursing (please state if you have been in the last 9 months?
Are you over the age of 18?
Allergies
Do you have any allergies or have you ever experienced allergic reactions to any kinds of medicines, foods, skincare products or products like latex gloves, plasters etc.?
Do you or have you ever suffered an allergic reaction to any local/topical anesthetics such as Benzocaine, Lidocaine, Tetracaine or Epinephrine?
Do you have an allergy to Aloe Vera, Silver, Colloidal Silver or SPF?
Medical History
Have had a hysterectomy in the last 6 months or do you intend to have one in the next 12 weeks?
Have you suffered with any form of diagnosed hormone imbalance in the last 9 months?
Are you currently undergoing any medical treatment and/or have you received any medical treatment within the last 6 months?
Are you currently taking any medication or supplements?
Do you knowingly suffer from any infectious diseases or any other acute or chronic diseases?
Do you suffer from uncontrolled, high or low blood pressure?
Do you have any other kind of circulatory issues or deficiencies?
Do you suffer from epilepsy, dizziness, fainting attacks or any other seizure related condition?
Are you taking any anti-coagulant (blood thinning medications)?
Do you suffer from an auto-immune disease such as Lupus, MS, Shingles, Psoriasis etc.?
Do you suffer from diabetes?
Do you have any respiratory problems such as Asthma or pulmonary problems like Emphysema, COPD or Bronchitis?
Do you have any heart problems or conditions?
Do you have a pacemaker?
Do you have any other cardiovascular condition?
Do you suffer from kidney and/or liver disease?
Do you suffer from blood disorder such as Anemia, Thalassemia, Polycythemia, Leukemia, Lymphoma, MDS, Myeloma and Thrombocythemia?
Do you have any history of malignant cancer?
Do you suffer from Hepatitis?
Have you ever had an organ transplant?
Do you suffer from HIV/AIDS?
Have you ever had/have from Herpes Simplex Virus (commonly referred to as cold sores)?
Have you ever had any recent Permanent Make Up (PMU) or cosmetic treatment?
Do you have any prosthetic implants or any plates or pins in the area being treated?
Optical
Are you wear contact lenses?
Are you currently wearing eyelash extensions?
Have you had Laser Eye Surgery in the last 3 months?
Do you have any major visual impairment?
Do you currently have a corneal abrasion or retinal detachment?
Do you have Glaucoma, Cataracts, Dry Eye, Styes/Conjunctivitis or Frequent Eye Infections?
General Health
Are you in good physical and mental health?
Are you currently under the influence of alcohol or drugs?
Do you suffer with body dysmorphia?
Do you feel fit, well and informed enough to have a skin treatment?
Are you aware that, post-treatment, you may not look your best for the next few days, that there will be period of downtime, that you may potentially experience some minor discomfort, redness and swelling and that you are expected to follow an aftercare regime?
Is there any other ailment or reason you feel we should know about which could prevent us from delivering your skin treatment?
I understand, I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Thanks for submitting!

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