CONSENT FORM

Kindly complete this form prior to your visit. We cannot wait to see you!

Name

First Name

Last Name

Email

Phone

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Address

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City

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State

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Zipcode

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Date of Appointment

MM

DD

YYYY

What services are you receiving?

What skincare products are you currently using?

Do you have any allergies?

Do you have and underlying medical conditions?

Are you pregnant or trying to become pregnant?

Have you used Renova, Retin-A, AHA's or Retinol/Vitamin A derivative products in the last 3 months?

Have you received Collagen, Restylane, Botox, or Filler injections in the last 6 months?

By printing your full name below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I understand that withholding information or providing inaccurate details about my medical history, allergies, and medications may lead to adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information.

Date Signed

MM

DD

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