consent form

    Client Information

    Health

    1. Do you suffer from any allergies?

    2. Do you wear contact lenses?

    4. Are you pregnant or trying to become pregnant?

    5. Have you had any surgery in the last 6 months?

    6. Have you had any of these health problems past or present?

    Lifestyle

    7. Are you on a restricted diet?

    8. Do you exercise regularly?

    9. Do you get an adequate amount of sleep?

    10. Do you drink alcohol?

    11. Do you smoke?

    12. On average, how many cups of tea or coffee would you consume daily?

    Professional Skin Care Treatments

    14. Have you consulted us before?

    15. Please tick main skin concerns:

    16. Do you prefer a firm or light massage?

    General Questions

    17. Would you like to be notified about any of our special events/promotions?

    Clinical Treatments

    18. Have you recently had micro-dermabrasion, laser, electrolysis or intensive peels?

    19. Have you recently had Botox/fillers, cortisone, Roaccutane, Retin-A? YesNo

    20. Are you aware of the various secondary effects following Glysalac clinical peels and Dermoboosters?

    Consent

    I authorize Spa Moment to perform a range of treatments including but not limited to laser skin and hair treatment, HIFU, Chemical Peeling, fat freezing, Injectables and other skin or body treatments.

    Contraindication: The procedure may not be able to perform if you have following condition:

    • Pregnancy, other gynecology issue.
    • Han implantable pacemaker or any other electronic implantable, teeth implant.
    • Post laser, injection, peeling treatment within one week.
    • History of applying prescriptions required cream or medication.
    • History of keloid skin or thyroid dysfunction.
    • Mental health disease, uncontrolled diabetic or generally unhealthy.

    I understand that potential risks of the treatment are rare, but possible. Common side effects include pain, stinging, itching, tingling, swelling, temporary numbing, redness, blister, bruises, scarring and mild ‘sunburn’ like effects. Local muscle weakness reaction, headaches, infections (rare).

    In addition, I understand that there is a possibility of accidental eye injury by the laser beam, Although unlikely due to standard precautions.

    After the treatment you should:

    • Avoid touching the treated area or applying makeup for 4 hours
    • Apply a cool compress to treatment areas to help reduce swelling.
    • Avoid strenuous exercise, saunas and spas for 48 hours.
    • Contact the clinic if pain or discoloration forms in the treatment area.

    I have discussed the proposed laser treatment with clinic staff, I understand the risks involved and have had all my questions answered to my satisfaction. I understand that no guarantee or promise as to the results can be different depends on individual response to the treatment.

    Do not sign this form unless you have read it and believe that you understand it. Ask any questions you might have before signing this form. Do not sign this form if you have taken medications which may impair your mental abilities or if you feel rushed or under pressure.

    I have read this form and understand it, and I request the performance of the procedure.

    I have read and understood the form, and I request the performance of the procedure.

    Client's Signature:

    Date:

    Print Name:

    Therapist: