Ultima Hair Design - NJ Salon & Day Spa

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 SPF of 15 must be applied.

Cleanse your face with water or a mild soap substitute that wil be recommended by your therapist. Twice daily followed by a mild sunscreen such recommended by your therapist, (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 therapist immediately.

CLIENT CONSENT-MICRODERMABRASION

I have read the above information and initialed each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist. I give permission to my therapist, Virgina, to perform the microdermabrasion procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over the counter or prescription medications that I use regularly and I am not presently using isotretinoin (Accutane). I have not had any facial surgical procedures or other chemical peels or skin treatments that I have not disclosed to my therapist. I am not ingesting or using topically any other over the counter product or prescription medication/agent that has not been disclosed to my therapist. I am not presently pregant or lactating and I am over the age of 18 (eighteen). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, or any other existing condition that may interfere with the positive outcome of this treatment.

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.

My expectations are realistic and I understand that the results are not guaranteed.

I agree that I am willing to follow recommendations by my esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my esthetician and I acknowlege that I have been informed of the possible negative reactions 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 therapist 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 limitation. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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.

Date:
Name:
Date of Birth
Address
Business Phone
Cell Phone
E-mail Address
Single Yes No	Married Yes No
	if yes anniversary date:

Employer
Occupation:
Referred by:
Does your job require that you work outdoors?	Yes No
What would you like to achieve from your treatment today?

YOUR SKIN CARE
Have you ever had a facial treatment before?	Yes No
If YES, when?
Have you ever had a body spa treatment before?	Yes No
If YES, when?
Massage	Yes No
Salt Glow	Yes No
Seaweed Wrap	Yes No
Moor Mud	Yes No
Body Scrub	Yes No
Other

Which of the following describes your skin type? Please choose one type
Creamy Complexion	Always burns easily, never tans
Light Complexion	Always burns, tans slightly
Light/Matte Complexion	Burns moderately, tans gradually
Matte Complexion	Seldom burns, always tans well
Brown Complexion	Rarely burns, deep tan
Black Complexion	Never burns, deeply pigmented

Do you have any special skin problems or concerns pertaining to your face or body?	Yes No
Specify

Have you ever had chemical peels, laser or microdermabrasion?	Yes No
In the last month?	Yes No

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?	Yes No
Describe

Have you used any of these products in the last 3 months?

Yes No

Have you used an acne medication?	Yes No
If yes, when and which drug

What skin care products are you currently using? (List brand where known)
Soap
Toner
Mask
Eye Product
Cleanser
Day Moisturizer
Exfoliator
Scrubs
Shower Gels
Body Lotions
Sunscreen
SPF
Night Moisturizer/Cream
Other
Makeup Products

Have you recently used any self-tanning lotions, creams or treatments?	Yes No
If yes specify

Have you used any of the following hair removal methods in the past six weeks?	Yes No
Check all that apply
Shaving	Waxing
Electrolysis	Plucking
Tweezing	Stringing
Depilatories

What areas of concern do you have regarding your Skin:
Check all that apply
Breakouts/Acne	Blackheads/whiteheads
Excessive oil/shine	Rosacea
Broken capillaries	Redness/ruddiness
Sun spot/liver spot/brown spot	Uneven skin tone
Sun damage	Wrinkes/fine lines
Dull/dry skin	Flaky skin
Dehydrated	Other:

Eyes:
Dehydrated	Wrinkles
Puffiness	Dark circles
Other

Lips
Dehydrated	Cracked/chapped
Other

Have you ever had an allergic reaction to any of the following, (please check all that apply and expain in the box provided below).
Cosmetics	Medicine
Food	Animals
Sunscreens	Iodine
Pollen	AHA's
Fragrance	Shellfish
Latex	Drugs
Other
If yes, please explain:

What SPF do you use on your face?
How often/When?

What SPF do you use on your body?
How often/When?

Have you had any recent tanning bed or sun exposure that changed the color of your skin?	Yes No
Specify:

Have you experienced Botox, Restylane or Collagen injections?	Yes No
Specify:

Female Clients only:

Are you taking oral contraceptives?	Yes No
Specify:

Any recent changes to or from your contraceptive treatment?	Yes No
If yes, what and when:

Are you pregnant or trying to become pregnant?

Yes No

Are you lactating?

Yes No

Any menopause problems?	Yes No
Please specify:

Are you undergoing any hormone replacement therapy?	Yes No
Please specify:

MALE CLIENTS ONLY:

What is your current shaving system?

Wet shave Electric

Do you experience irritation from shaving?	Yes No
Ingrown Hairs?	Yes No

Please use this area to complete any answers from above or to add any additional information

Future Appointments/Contact:

May I call you at your home, work or cell phone number to confirm future appointments?	Yes No
May I contact you via email/mail about future promotions and news?	Yes No

I understand, have read and completed this questionairre 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.

Please enter today's date:

I read all of the information provided above and by checking the box I agree to all terms stated.

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