Medical Release Form
Confidential Client Medical History
City State Zip Code
Cell Phone Work Work
May we text you appointment reminders? Yes No
If yes, please provide your telephone carrier name
How did you hear of us?
General Medical History
Have you had a negative reaction to chemical peels? Yes No
Existing Skin Conditions (Check all that apply)
What skin care line(s) do you use?
Allergies (Check all that apply)
Please list any other allergies below:
Medical and Dietary Supplements
What oral medications are you presently taking?
Do you regularly take Baby Aspirin, Coumadin or other Blood Thinners? Yes No
What topical medications or creams are you currently using?
Are you on photosensitizing medications such as Tetracycline or Retin-A? Yes No
Do you take fish or flax oil supplements? Yes No
Ginkgo? Yes No
What other dietary supplements do you take regularly?
Female Clients Only
Are you pregnant or trying to become? Yes No
Are you breast feeding? Yes No
Are you using hormonal contraception? Yes No
When is your next period
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, doctor or nurse of my current medical or health conditions and to update this history. I understand there are no refunds offered on unwanted treatments and no returns are given for treatments with unsatisfactory results.
Skin Typing Worksheet
Skin Score (Total Number)
|0 - 7
|8 - 16
|17 - 25
|26 - 30
||V - VI
Patient Consent for Custom Chemical Peel, Enzyme Treatment or Facial
I hereby authorize and direct any associates or employees of Vasu, Inc to perform a custom chemical peel, enzyme treatment or facial on me. Multiple treatments are required to achieve cosmetically acceptable results. I specifically acknowledge that no guarantees or warranties have been made concerning the results of the procedure.
The following points have been discussed with me and I understand: (please initial each statement)
I have been fully and completely informed of all possible side effects including pain and scarring associated with this treatment.
The most likely possible complications or risks involved with chemical peels, enzyme treatments or facials include but are not limited to burns, blistering with infection and scaring, scabbing, herpes simplex virus activation, itching, red-purple discoloration, bruising and longterm pigmentary changes. Hypo-pigmentation or hyper-pigmentation could be permanent.
I do not meet any of the exclusionary factors such as the presence of herpes simplex, I have refrained from using topical retinoids (Differin, Adapalene, Tretinoin, Renova, etc) or waxed within 10-15 days of the procedure. I have not had surgery, laser treatments,
dermabrasion or other treatments within the past month.
I hereby authorize Vasu, Inc or any associates to take pictures of the treated area to be used in my patient file and/or teaching purposes. I understand that the release of this information will be kept confidential and that no patient names will be used.
I am not pregnant (female patients) and shall notify Vasu, Inc, if that changes.
I have been given the opportunity to ask questions about the procedure(s). My questions have been answered and I understand the information given to me.
Contraindications to the performance of this procedure(s) have been discussed in detail with me and I understand that my skin’s condition may actually temporarily worsen as a result of this treatment.
I recognize that the practice of chemical peels, enzyme treatment and facials is not an exact science and acknowledge that no guarantees have been made to me concerning the results of such procedures and thus no monetary refunds will be issued to me on any previous or future treatments.
I understand that immediately following the treatment, the treated area may appear red and may have edema (swelling). The redness (erythema) and discoloration may take up to 6 months to heal. The treated area may feel like a sunburn for a few hours after treatment.
I have received the aftercare instructions. Compliance with recommended aftercare guidelines are crucial for healing, prevention of scarring and hyper-pigmentation.
I understand and agree to give at least 24-hour cancellation or re-scheduling notice and I agree to pay a minimum of $50.00 or forfeit my treatment if I don’t give proper notification. If I cancel the same day of my scheduled appointments, I agree to pre-pay for any future
appointments. Such payment will be non-refundable and non-transferable.
I give consent to this treatment.
I understand that I release Vasu, Inc and its associates, the Medical Director, the technician performing the procedures and any other person involved in my treatment from any liability associated with complications from the procedure. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize my treatment by the staff of Vasu, Inc.
(PURSUANT TO 45 CFR 164.508)
“This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.”
Vasu Skin Solutions is dedicated to protecting the private and medical information of our patients.
It is our firm policy not to share any client information without written permission from the client. Below is a brief summary of our policy and disclosure permission form. If you already have someone in mind that might need access to your medical records, please list that person below.
Vasu’s, policy was put in place to protect your “protected health information” or “PHI”. Therefore we will not discuss any information with you, or anyone else, without first verifying your identity by date of birth, address and getting your written permission to do so.
Your PHI will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers if desired, laboratories and health insurance payers as it necessary and appropriate for your care. Your signature below indicates that you understand and accept Vasu, Inc’s privacy policies. The full description go our privacy policies are located here: www.vasuskinsolutions.com/about-vasu/policies
Release of Information (Check the appropriate boxes and complete the requested information)
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
Information is not to be released to anyone except self.
This Release of Information will remain in effect until terminated by me in writing.
Please call my home my work my cell number:
If unable to reach me:
you may leave a detailed message
please leave a message asking me to return your call