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Client Intake, Treatment Consent Form and Cancellation Policy

Thank you for taking the time to fill out this client information sheet. This is strictly confidential and will be used only to help us attain the best results for your skin.

 

 

CANCELLATION AND NO-SHOW POLICY

 

We charge $50 for same day cancellations and Full-Price for NO CALL NO SHOW for reserved therapist time and treatment room.

NO EXCEPTIONS

Kindly give a 24-Hour notice if you need to cancel or reschedule your appointment in order to avoid a charge.

We send out reminder emails, text messages and phone calls as a courtesy but it is still the patient’s responsibility to keep track of their appointment schedule as well as up-to-date contact information with the front desk

Patient acknowledges and agrees to this policy:


Treatment Consent Form

 

MICRODERMABRASION          

MDSE         

ISOGEI

MICROGEI                

CHEMICAL PEEL          

FLASH REJUVENATION

HYDRAFACIAL             

MICROCURRENT          

OXYGEN

FIBROBLAST SKIN TIGHTENING

This consent is designed to give you the information you need to make an informed choice on whether or not to undergo a chemical peel, microdermabrasion, light therapy or any other of our skin procedures. If you have any questions please do not hesitate to ask. While our skin treatments are effective in most cases, no guarantee can be made that a specific patient will benefit from the treatment.

I understand this treatment causes a light burning sensation what will last one to several minutes and in the rare circumstance hours. I also understand that this treatment may need to be done more than once, depending upon my skin type and nature of my problem.

At an early stage of treatment, the site of the peel may or may not undergo the following conditions:

  1. The skin may feel tight for 2-3 days after the application of the solution. It may darken on the second day or early on the third day, then start to peel. This usually looks like a brown scratch or small patch. It is a very light and thin scab. Do not peel this manually let it come off when it’s ready. The peeling will be completed in 2-3 more days. When deeper peels are necessary, the peeling may last 1-2 weeks. Swelling around the eyes also may take place with deeper peels.
  2. The skin may feel dry and itchy and a mild stinging sensation may also be present. Adherence to the home/ post care instructions should ease any discomfort, which usually subsides when the peel is completed. The deeper the peel, the more time is needed for healing, and can last up to two weeks or more.

Possible Complications:

Although very uncommon, complications can occur. Pay careful attention to any instructions provided by the doctor and/or esthetician. Contact us if you have any concerns.

ALWAYS WEAR BROAD SPECTRUM SUNCREEN SPF30 OR HIGHER.

Most of the known possible side effects respond to injections or special creams; however, some scarring may be permanent. Allergic reactions, irritation or scratching does subside and ordinarily disappears in a few months, but some scarring may be permanent.

The doctor and/or esthetician has explained to me the possible complications and I understand them. I understand that every person may respond differently to treatments due to their own unique health and biological condition. Medical treatment is not an exact science. The degree of improvement is variable. Occasionally, there is no improvement and another form of treatment may be required.

By signing below, I acknowledge that I have read foregoing ‘CLUB SKIN GYM’ TREATMENT CONSENT FORM and that I feel the doctor and/or esthetician has adequately informed me of possible risks.

 

Date: April 20, 2024


Customer Source
How did you hear about us?*
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Gender:*

List any drugs you currently take (inc. aspirin, vitamins, herbs, prescription drugs):

Known Allergies (include cosmetic products, food and drug allergies):

List any skin treatments you have had in the past:

What skincare products do you currently use?
Do you currently or have ever had cold sores?*
No
Yes
Are you currently or have you ever taken the drug Accutane?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Are you having hormonal changes that may affect your skin?*
No
Yes
Do you have a history of skin cancer in your family?*
No
Yes
Do you use sunscreen?*
No
Yes
Have you had your skin checked by a Dermatologist?*
No
Yes
Do you tan in tanning beds or spray tan?*
No
Yes
Which of the following concerns you?
Fine Lines and Wrinkles
Skin Texture
Rosacea
Large Pores
Brown Spots
Sagging Skin/Volume Loss
Acne scars

Who may we thank for referring you?

I have read and understand the consent form

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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