Name * First Name Last Name Phone * (###) ### #### Are you currently using any retinoids (Retin-a, Retinol, Tretinoin, ect)? * Yes No Have you used any Alpha Hydroxy Acid (AHA) or Glycolic products in the last 48-72 hours? * Yes No Are you currently using any topical and/or oral prescription Acne Medication? If, yes please list below. * Are you Diabetic? * Yes No Do you have any Botox or Fillers ? If yes, when was your last injection? * Are you currently taking any medications not listed above? If yes, please list all (including over the counter drug/herbal supplements) * Have you ever been treated for cancer? If yes, when and what types of therapies were used? * What skin products do you regularly use on your skin? * Please give details and brand names Please list any Allergies * or known irritants Please list any additional illness/conditions you are currently being treated for by a medical professional. * Do you have any medical devices implanted such as a pacemaker? * Yes No Are you currently pregnant or breastfeeding? * Yes No I give permission to my therapist to perform the scheduled procedure and or skin treatment that we have discussed. I will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs 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 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. I understand the procedure and accept the risks. I do not hold my esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. * Checking YES releases Veracity Skin Studio of all liability Yes No Thank you!
