Client Health Questionnaire
Do not leave any fields blank
Today's Date:
Client or Parent/Legal Guardian Name:
Date of Birth: Gender:
Phone: Email Address:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
*May we contact you by phone?
Yes No
*Would you like to be contacted via Email?
Yes No
To whom may we send a thank you note for referring you to our clinic?
Occupation:
*Ethnicity: (Please Check One)
Asian
African American
Caucasian
Hispanic
Native American
Other:
*Emergency Contact Person:
*Emergency Contact Phone:
Medical & Surgical History
*Do you have any allergies?
Yes No
If Yes, please list:
*Do you currently take any medications (including over-the-counter meds)?
Yes No
If Yes, please list:
*Please check all that apply:
Please explain in detail any checked conditions above:
Please answer each question below (must complete):
*Do you have a pacemaker or implanted defibrillator?
Yes No
*Do you have any metal pins, plates, dental fillings, etc.?
Yes No
*Are you currently pregnant or breast feeding?
Yes No
*Have you taken Accutane?
Yes No
If yes, when?
*Have you ever used Retin-A?
Yes No
If yes, when?
*Are you prone to Keloid Scarring?
Yes No
*Do you have any tattoos or permanent makeup?
Yes No
If yes, where?
*Do you use self-tanner?
Yes No
If yes, when was the last time?
*Have you had Vein Therapy?
Yes No
If yes, what type and when did you have it done?
Current products used on the skin:
Organic Facial Consent
Guest name: Date:
I understand that the service(s) requested to be performed on me by Deify Laser + Beauty Lounge Inc. is (are) purely elective and that:
There are potential side effects, including but not limited to: Dryness, sensitivity, tiny scabs (where older acne impactions were removed) and flaking are normal and temporary. Superficial temporary dark spots may occur after the extraction of older or deeper lesions and fade rapidly.
- Sun exposure or use of tanning lamps or self-tanning creams and not adhering to the post-care instructions provided may increase the likelihood of complications.
- If I am pregnant or nursing, I understand that I should consult my physician before undergoing any treatments.
- The service(s) may require multiple treatments for positive results. The total number of treatments may vary between individuals. Some individuals may not respond to treatment.
- I understand I may or may not actually peel and that each case is individual. I understand that the amount of peeling does not correlate with degree of improvement.
- I have not had any other chemical peel of any kind within 14 days of this treatment. I understand I cannot have another chemical peel within 14 days of this treatment, whether it is performed at this location or any other location.
I I understand that organic facials include exfoliation with steam and dead cell-dissolving enzymes that soften clogged pores and comedones, facilitating their evacuation), extractions with sterile instruments, either a calming or brightening mask, optional antibacterial, exfoliating or brightening boosters, a soothing inflammatory lotion, and sun protection. Superior results are achieved when prescribed home care products are used as directed. They penetrate the follicle, softening impactions (blackheads, clogged pores) making extractions easier to perform, less uncomfortable, and less necessary.
I acknowledge that pre and post treatment instructions have been provided and discussed with me and that I understand all such instructions. The elected service specified above, as well as alternative service options and the potential benefits and risks of each have been explained to my satisfaction. I have had all my questions answered.
I understand the requested and specified service(s) and accept the risks. I hereby release Deify Laser + Beauty Lounge Inc. from any and all injuries, actions, causes of action, suits, damages, judgments, claims, and demands whatsoever, in law or equity, which I shall or may have, for, upon, or by reason of the performance or non-performance of the above indicated services.
Cancellation of an Appointment
In order to be respectful of all guests, please be courteous and call us if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel or reschedule your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to this appointment slot.
How to Cancel Your Appointment
To cancel or reschedule appointments, please call us a minimum of 24 hours in advance of your appointment. If you do not reach the receptionist, you may leave a detailed message on our voicemail. If you would like to reschedule your appointment, please leave your phone number. We will return your call and give you the next available appointment time.
Late Cancellations:
A late cancellation is considered when a patient fails to cancel or reschedule their scheduled appointment with a 24-hour advance notice.
No Show Policy:
A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your file as a "no-show."
First missed appointment: $50 fee will be billed to your account
Third missed appointment: $50 fee will be billed to your account and you may forfeit sessions.
I have read and understood all information presented to me before signing this consent form.