Consultation Form

First Name

Last Name

Telephone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Your Birthday Date

How did you hear about us?

Treatment / Record

Date

Skin Therapist

Samples

Notes

Consultation

Please answer these questions to help us provide the best service for your skin.

Your Health

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

Yes

If yes, please specify:

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

Do you wear contact lenses?

Yes

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

Yes

Do you have any allergies?

Yes

If yes, please specify:

Do you have any sinus problems?

Yes

Have you ever experienced claustrophobia?

Yes

Your Skin

What are your specific concerns/challenges with your skin?

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

Yes

Have you been waxed with the last 72 hours?

Yes

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

Yes

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)

This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.

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.

Date

Full Name

Pro power peel consent for treatment

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 light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?

Yes

Do you have active cold sores?

Yes

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

Yes

Do you sunbathe or using tanning beds?

Yes

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

Yes

I release and waive any claims against Glowskin, Dermalogica, LLC and their affiliates and subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, 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, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Glowskin and Dermalogica.

I have received Post-Care instructional sheet.

Yes