Confidential Consultation Card

Consultation Card

Name______

LAST MIDDLE FIRST

Address______Email: ______

City______State___ Zip______Mobile:______

Phone: Home( )______Work( )______Date: / /

Have you been exposed to the sun or sun beds recently? Y/N When?______

Are you allergic to the following: Grapes? Y/N Aspirin? Y/N Milk? Y/N Citrus? Y/N Apples? Y/N Vitamin A? Y/N Tomatoes? Y/N Hydroquinone? Y/N Are you pregnant? Y/N Within the last 7 days have you been waxed/lasered? Y/N Injections? Y/N Menopause problems? Y/N Hormones?Y/N Hemophiliac? Y/N Are you Claustrophobic? Y/N Epileptic? Y/N Arthritic Y/N Asthmatic? Y/N Diabetic? Y/N AIDS? Y/N

Do you ever break out? Y/N Cystic Acne? Y/N Hepatitis? Y/N Type: A/B/C

In past year have you been under Dr.’s care? Y/N Why?______

Any heart problems? Y/NPacemaker? Y/N Do you smoke? Y/N

Do you wear contact lenses? Y/N Has your immune system been compromised? Y/N When:______Any pins,metallic or cosmetic implants? Y/N Any skin problems? Y/N If yes, explain ______Any allergies? Y/N If yes, to what? ______

Any skin cancer? Y/N If yes, explain______

Any recent surgery? Y/N If yes, explain______Any plastic surgery? Y/N If yes, explain______Are you currently taking any medications? Y/N ______

Do you use Retin A or Renova? Y/N Have you used Accutane?Y/N

Have you ever had an Acid Peel? Y/NUsing any acne medications? Y/N

Do you use Glycolic Acid products? Y/N Do you use topical Vit. C? Y/N

What products do you use on your face?______

Do you blush easily? Y/N Tightening of the skin? Y/N Flaky skin? Y/N

Do you feel any burning or itching of the skin? Y/N Do you have any oily areas? Y/N Have you ever had a facial before? Y/N When/Where: ______

Which conditions do you want to improve? (circle) Dark Spots Acne Fine Lines & Wrinkles Sun Damage Enlarged Pores Scarring Dryness Excess Oil

How would you like to improve your skin?______How did you hear about us? ______If a friend, please let us know who to thank:

Waiver Agreement Contract

The undersigned acknowledge that Corrective Skincare Center, Inc. D/B/A Cary Skin Care, has explained the nature of all the above-noted treatment procedures including the risks and dangers inherent. I hereby consent to Corrective Skincare Center, Inc. (D/B/A Cary Skin Care) performing the above treatment procedures on me and in consideration of their doing so. I hereby release and forever discharge Corrective Skincare Center, Inc. (D/B/A Cary Skin Care) its officers and employees of and from all claims, damages, demands, actions or causes of action arising out of the performance of the said treatment procedures. Which I, my heirs executors, administrators or assigns can, shall or may have. Sorry, no refunds on any treatments or products

Signature:______Date:______

Witness:______

General Consent Form

It is your responsibility to inform the skin therapist of any pre-existing conditions, limitations or specific skin sensitivities. You understand and voluntarily accept any risks of which you have been advised associated with your skin therapy or from any use of the company’s facilities and hereby release Corrective Skincare Center, Inc. D/B/A Cary Skin Care (including its employees, practitioners, agents and insurers from all liability for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you resulting there from. You further hereby release all of the foregoing personnel and entities from all inability arising from any such injury or damage resulting from your failure to disclose any pre-existing condition, limitation or specific sensitivities or your failure to inform your therapist of any discomfort during the session. Your therapist may determine it unsafe for you to proceed with or continue treatment due to health related skin concerns. In this event, you may be required to provide Corrective Skincare Center, Inc. (d/b/a Cary Skin Care) with a physician’s medical release prior to continuing treatment. I also accept responsibility to inform my skin therapist of each change in my current health and/or medications I am taking throughout my skin care treatments at Corrective Skincare Center, Inc. (d/b/a Cary Skin Care)

Waiver Agreement Contract

The undersigned acknowledges that she has read this agreement.

Signature:

______Date: ______

Micro-Current & Ultrasonic Consent Form

Contra-indications for microcurrent and ultrasonic therapy include: Cardiac pacemakers, epilepsy, metal implants, pregnancy, and cancerous lesions.

I acknowledge that I do NOT have any of the previously mentioned contra-indications.

Waiver Agreement Contract

The undersigned acknowledge that Corrective Skincare Center, Inc. (D/B/A Cary Skin Care) has explained the nature of all the above-noted treatment procedures including the risks and dangers inherent. I hereby consent to Corrective Skincare Center , Inc. (D/B/A Cary Skin Care) performing the above treatment procedures on me and in consideration of their doing so. I hereby release and forever discharge Corrective Skincare Center, , Inc. (D/B/A Cary Skin Care) its officers and employees of and from all claims, damages, demands, actions or causes of action arising out of the performance of the said treatment procedures. Which I, my heirs executors, administrators or assigns can, shall or may have. No refunds on any treatments or products.

Signature:______Date:______

Witness:______

L.E.D. Light Therapy Consent Form

Prior to receiving L.E.D. Light Therapy Treatment, I have been candid in revealing the following:

I am NOT pregnant &

I do NOT have epilepsy

I understand that there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc.

I understand that to achieve maximum results, I may need several treatments.

Waiver Agreement Contract

Signature:______Date:______

Witness:______

Microdermabrasion Consent Form

Microdermabrasion projects a flow of inert crystals over the skin, and abrades away epidermal tissue in the areas treated. It is done so precisely that normal surrounding tissue is hardly affected. Microdermabrasion is often used to treat acne, reduce the appearance of scars, wrinkles, hyperpigmentation and other skin conditions.

After a treatment the skin may feel tight and warm as if exposed to the sun or wind. Slight redness and swelling may appear with deeper treatment levels in addition to slight blood spotting. Healing may take several days or longer.

Your fresh newly exposed skin will be delicate. It is important that you use a mild basic cleanser and keep the skin well moisturized particularly around the delicate eye area. You should use a full spectrum sun block daily. A mineral sun block (non-chemical) is less irritating to the skin. Avoid the use of Retin-A, Renova, alpha or beta hydroxy type products and all forms of scrubs for at least 48 hours, or until the initial sensitivity has subsided. Do not apply ordinary make-up base for at least 24 hours after a treatment. Avoid swimming and tanning beds for at least one week.

Any time the skin barrier is broken, there is a small risk of bacteria or viral infection.

I acknowledge that no guarantee has been given to me regarding the condition of my skin or the percentage of improvement expected following treatment. I understand that no specific results are guaranteed.

My signature below constitutes acknowledgment that I have read and understand the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to Corrective Skincare Center, Inc. (D/B/A Cary Skin Care) to perform microdermabrasion treatments.

Waiver Agreement Contract

Signature:______Date:______

Witness:______

Peels Consent Form

Prior to receiving treatment, I have been candid in revealing any condition that may have bearing on this procedure, such as Pregnancy (if so do not do treatment), recent facial surgery, allergies, tendency to cold sores/fever blisters, use of retin-A, Accutane or hormones.

I understand that there may be some degree of discomfort, i.e., stinging, pin-pricking sensation, hotness or tightness.

I understand there are no guarantees as to the results of this treatment, due to many variables, such as: age, condition of skin, sun damage, smoking, climate, etc. I understand, if receiving a peel treatment, I may or may not actually peel, that each case is individual.

I understand that to achieve maximum results, I may need several treatments.

I understand that although complications are rare, sometimes they occur and I will immediately contact the technician who performed the treatment.

I agree to refrain from tanning outside or tanning booths while undergoing treatment and during the 14 days following the end of treatment.

I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum of SPF 20 is mandatory.

I have not had any other peel treatment of any kind within 14 days of the treatment.

I agree to all of the above and agree to have this treatment be performed on me. I further agree to follow all post-peel care instructions as I am directed.

Waiver Agreement Contract

The undersigned acknowledge that Corrective Skincare Center, Inc. D/B/ A Cary Skin Care, has explained the nature of all the above treatment procedures including the risks and dangers inherent. I hereby consent to Corrective Skincare Center, Inc. D/B/A Cary Skin Care, performing the above treatment procedures on me and in consideration of their doing so. I hereby release and forever discharge Corrective Skincare Center, Inc. (D/B/A Cary Skin Care) its officers and employees of and from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures. Which I, my heirs executors, administrators or assigns can, shall or may have. No refunds on treatments.

Signature: ______Date______

Witness:

______

Post Care Instructions for Microdermabrasion & Peels

Tonight: Only use Post Balm Ointment and Calming Skin Gel before bedtime. Do not wash your face tonight, allow it to rest.

Do not get into a hot shower or steam of any kind, no saunas, hair dryers, this can cause brown spotting on your face if you get too hot.

Tomorrow Morning:

1-Gentle Cleanser (Citrus Gel or Milk Plus Wash- No over the counter cleaners unless approved)

2-Regenerating Cream (or Growth Factor Gel/Growth Factor Serum) a.m. & p.m.

3-No Makeup Except Mineral Based (No Over the counter liquid makeup, it harbors bacteria and is subject to infections)

No over the counter ANYTHING for at least 4-10 days. Please ask if you have a question about this.

No Acne Products or Acne Prescriptions for 7-10 days. These will over dry and possibly burn the skin.

For the next 1-2 weeks:

Cleanse gently and apply ONLY: Post Balm Ointment, Calming Skin Gel & Regenerating or Growth factor gel/serums & SPF until completely healed with no redness or sensitivities.

No Tanning outside or indoors Always wear SPF 30+

No Swimming in Chlorine Water Until Face is Completely Healed

No hair coloring, bleaching or perms until your skin is normal

Stay away from any airborne chemicals after treatments, including cleaning products-this can cause rashes

No AHA’s (alpha hydroxys), BHA (salicylic acids, etc.), Retinol/Organic A serum, Vitamin C serum, Skin Refining Gel, Skin Smoothing Gel, Retin-A, Any Topical Prescription Acne Products, harsh scrubs, loofas or anything exfoliating, botanicals, no over the counter products (or Mary Kay, etc.) and absolutely no over the counter “anti-aging” or acne products, creams or serums. Fragranced and botanical ingredients are very irritating to new fresh skin. If you have any questions about what you should not be putting on your face, contact me.

No Electrolysis or Laser on treated skin

No Waxing for 5-7 days

Protect your face from hot and cold weather and situations. Your skin is fresh and has no protection and is more susceptible to infections, wind/sun burns etc. Treat it like you would a baby’s skin.

No Botox, Fillers or any injections for 10 Days

If you see any discoloration, redness (after 12 hours), irritation, scabbing, brown areas, blistering or pain call me IMMEDIATELY.

Cold Packs will help during the first 24 hours for redness (no more 15 min. per hour)

NEVER pick at your skin. If your skin flakes or peels, please moisturize it only.

Final results will be 3-4 weeks post treatment

Post Peel Skin Treatment Information

You have just received a chemical peel. It is best do not apply makeup the day of treatment. Allow the skin to rest overnight. Apply Rengerating Cream, Post Balm or Drops of Essence FREQUENTLY. Carry it with you everywhere. You may experience light “exfoliation”. Everyone’s skin responds differently. Most people look normal the day of treatment. Do not apply BHA, AHA, skin lightener products or harsh to your skin, as they will be too irritating to the skin. You must be off of Retin-A, or Renova at least 1 week. Peels have a cumulative effect. You will see a bigger difference the more peels you have.

Due to the nature of these treatments, you may not necessarily “peel”. However, you may have some flaking for the next several days. Most patients who have this treatment only have residual redness from 1- 12 hours.

Do’s & Don’ts:

AVOID direct SUN exposure, use 25+ SPF EVERY day. Be sure to get SPF that covers FULL spectrum UVA/UVB & Infra red rays!

ABSOLUTELY DO NOT GO TO A TANNING BOOTH FOR 2Weeks before or after a treatment.

FOR THE NEXT 2 DAYS:

Do not put face directly into hot shower or bath. Do not use Jacuzzis, steam rooms or saunas.

Do not go swimming in chemicals.

Stay cool, try not to perspire. Stay out of hot cars etc.

Do not direct a hair dryer onto treated area.

Do not use mechanical exfoliants (no buff puffs, or coarse scrubs)

Do NOT PICK at your skin

ABSOLUTELY, DO NOT TAN

Do not use lightening lotion or BHA or AHA’s on treated areas for the first 2 days.

DO NOT WAX or bleach your face area or use depilatories (like Nair), have electrolysis or collagen injections for 5 days.

Do not exercise. Stay Cool!

DO NOT GET HAIR COLORED OR PROCESSED!!!

For the first 24 hours:

You can expect slight pink to red skin. After 12 Hours, you may apply Post Balm & sunscreen SPF 25+ under makeup.

Tomorrow Morning:

Morning & Evening wash with Cleanser, Toner , apply Post Balm & SPF 20+ under makeup. Please only use mineral makeup. Skin may start to darken in some areas if hyperpigmentation treatment was given. This is normal and will peel off later (Do NOT pick at your skin)

3rd - 4th Day:

You may experience some exfoliating or dark skin this is normal. (DO NOT PICK AT IT). After you begin to peel, apply Regenerating Cream/Growth factors several times a day as needed. DO NOT PICK AT YOUR SKIN. If it peels, put on more regenerating or post balm cream. Use SPF 20+ Morning & Evening after your regenerating cream. Some times the growth factor stings. If so, use only post balm or mix post balm with the growth factors until less sensitive.

5th - 10th day:

Continue with applying Regenerating Cream or Growth Factor & SPF 30+ before makeup & in the evening before retiring.