Name *

First Name

Last Name

Phone *

(###)

###

####

Have you ever had any allergic reactions to any of the following? *

Algae

Animals

Aspirin

Cosmetics

Diary

Essential Oils

Food

Latex

Medicine

Niacin

Nuts

Shellfish

Sulfur

Sunscreen

NONE

Have you had any of these health conditions in the past or present (Please check all that apply)

Anemia

Any Active Infections

Asthma

Arthritis

Blood clotting disorders

Cancer

Gout

Diabetes

Emotional Disorder

Epilepsy Seizures

Fainting Spells

Gallstones

Heart Disease

Heart Attack

Herpes

Hepatitis

HIV/AIDS

Rheumatic Fever

High Blood Pressure

Digestive Problems

Ulcerative Colitis

Ulcer Disease

Kidney Disease

Liver Disease

Sleep Apnea

Skin Cancer

Use a C-PAP machine

Thyroid Problems

Tuberculosis

Venereal Disease

Neurological Disorders

Bleeding Disorders

Lung Disease

Emphysema

Keloid Scarring

Skin Disease/Skin Lesions

Metal bone Pins, Plates or Pacemaker

NONE

Are you using any oral & topical medications? *

YES

NO

Are you Pregnant or Nursing? *

YES

NO

Are you or have you been on Accutane within the past 6 months? *

YES

NO

Have you used Retin-A, Renova, AHA or Retinol derivative products within the past 5 days? *

YES

NO

Have you had Botox or Dermal Fillers? *

YES

NO

What areas of concern do you have regarding your skin? *

Blackheads/ Whiteheads

Breakouts/Acne

Broken Capillaries

Congestion

Deep Wrinkes

Fine lines

Discoloration

Dull/ Dryness

Oily skin

Does your skin get red or irritated easily? *

YES

NO

Do you wear Contact Lenses? *

YES

NO

Are you Claustrophobic? *

YES

NO

Alcohol Consumption *

I don't drink

1-2 glasses/week

3-4 glasses/week

5+ glasses/week

Do you smoke? *

YES

NO

For Microcurrent Therapy: *

Do you have any of the following?

Pacemaker

Pregnancy

Thombosis

Phlebitis

Epilepsy

Cancer

NONE

I understand that my facial treatment may include clinical-strength products, enzymes, acid peels, dermaplaning, extractions, ReZENerate, LED Light Therapy and other treatment modalities as necessary. *

I understand

I understand that if I'm getting dermaplaning, the treatment may involve the risk of complication or injury and I freely assume those risks. Possible side effects of the treatment area can include mild redness of the skin, irritation and dryness. Additionally, nicks to the skin can occur due to the surgical blade. Clients will be notified and the area will be treated if necessary. The hair is expected to grow back blunt-ended. New hair will not appear darker or denser, however I do understand that any hormonal imbalance that may be present within my anatomical system can alter my normal hair growth pattern. I understand that if I do decide to get a peel the sensation and penetration of the peel will be enhanced which may cause skin irritation, mild discomfort and tenderness. *

I understand

I have read and understand the Precare + Aftercare/FAQ's on service being provided and Policies section on the website. I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release ML Beauty Lounge against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment. *

I understand

I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol. *

I understand

I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking and climate. I may or may not experience actual “peeling” with this procedure as each case is individual. *

I understand

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

I understand

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact my Esthetician. *

I understand

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my 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 SPF 30 is mandatory. *

I agree

I will reveal any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior. *

I understand

I have not had a peel treatment of any kind within 14 days of my treatment at ML Beauty Lounge, I understand I cannot have another treatment until recommended by a licensed professional at ML Beauty Lounge. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by your Esthetician. *

I understand

PHOTOGRAPHS: I give permission for photographs to be used by your Esthetician: *

For monitoring my treatment progress

Social Media

Both

Neither

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform my Esthetician of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments. *

I understand

I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release ML Beauty Lounge against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment. *

I understand